Professional Documents
Culture Documents
EMA/369266/2014
Committee for Medicinal Products for Human Use (CHMP)
Translarna
(ataluren)
Procedure No. EMEA/H/C/002720
Applicant: PTC Therapeutics Limited
Table of contents
1. Background information on the procedure .............................................. 5
1.1. Submission of the dossier ....................................................................................5
1.2. Manufacturers ....................................................................................................6
1.3. Steps taken for the assessment of the product ........................................................6
1.4. Steps taken for the re-examination procedure.........................................................7
2. Scientific discussion ................................................................................ 8
2.1. Introduction .......................................................................................................8
2.2. Quality aspects ...................................................................................................9
2.2.1. Introduction ....................................................................................................9
2.2.2. Active Substance .............................................................................................9
2.2.3. Finished Medicinal Product ............................................................................... 11
2.2.4. Discussion on chemical, pharmaceutical and biological aspects ............................. 13
2.2.5. Conclusions on the chemical, pharmaceutical and biological aspects ...................... 13
2.2.6. Recommendation(s) for future quality development ............................................ 13
2.3. Non-clinical aspects........................................................................................... 13
2.3.1. Introduction .................................................................................................. 13
2.3.2. Pharmacology ................................................................................................ 13
2.3.3. Pharmacokinetics ........................................................................................... 17
2.3.4. Toxicology .................................................................................................... 18
2.3.5. Ecotoxicity/environmental risk assessment ........................................................ 21
2.3.6. Discussion on non-clinical aspects .................................................................... 21
2.3.7. Conclusion on the non-clinical aspects ............................................................... 23
2.4. Clinical aspects ................................................................................................. 24
2.4.1. Introduction .................................................................................................. 24
2.4.2. Pharmacokinetics ........................................................................................... 25
2.4.3. Pharmacodynamics ........................................................................................ 27
2.4.4. Discussion on clinical pharmacology .................................................................. 28
2.4.5. Conclusions on clinical pharmacology ................................................................ 30
2.5. Clinical efficacy ................................................................................................. 30
2.5.1. Dose response studies .................................................................................... 30
2.5.2. Main study .................................................................................................... 31
2.5.3. Discussion on clinical efficacy ........................................................................... 46
2.5.4. Conclusions on the clinical efficacy.................................................................... 51
2.6. Clinical safety ................................................................................................... 51
2.6.1. Discussion on clinical safety ............................................................................. 58
2.6.2. Conclusions on the clinical safety...................................................................... 60
2.7. Pharmacovigilance ............................................................................................ 60
2.8. Risk Management Plan....................................................................................... 60
2.9. User consultation .............................................................................................. 70
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List of abbreviations
6MWD
6MWT
AUC
ACTH
ALT
ANCOVA
AP
AST
BCRP
BCS
BID
BUN
CF
CFTR
Chol
cITT
CK
CNS
ECG
EC
EU
DBMD
DMC
DMD
DMF
DMSO
DNA
DSC
EC
EU
F
GC
GCP
GLP
Gluc
GMP
GRAS
Hb
Hct
HDPE
HEK293
hERG
HPLC
HRQL
ICH
IP
IR
ITT
IVR/IWR
KF
LD50
LOCF
LOEL
M
MCH
MCHC
MCID
MCV
MEFs
MMRM
Translarna
EMA/369266/2014
mRNA
nm
NMR
NOEL
NOAEL
OAT
PBMC
PBT
PCR
PD
PE
PedsQL
Ph. Eur.
PIB
PK
PPI
PTT
QC/QA
RBC
RH
RMP
RNA
ROI
SAE
SAP
SmPC
TFTs
TGA
TID
TSQM
UGT
UV
Vss
WBC
XRPD
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Similarity
Pursuant to Article 8 of Regulation (EC) No. 141/2000 and Article 3 of Commission Regulation
(EC) No 847/2000, the applicant did not submit a critical report addressing the possible similarity
with authorised orphan medicinal products because there is no authorised orphan medicinal
product for a condition related to the proposed indication.
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The product will address unmet medical need in a life-threatening and chronically
debilitating condition where no satisfactory methods of treatment exist.
The benefits to public health of the immediate availability outweigh the risks inherent in
the fact that additional data are still required.
It is likely that the Applicant will be able to provide comprehensive data based on
confirmatory study in nmDMD patients.
1.2. Manufacturers
Manufacturer responsible for batch release
Almac Pharma Services Ltd.
Seagoe Industrial Estate
Craigavon
Co. Armagh BT63 5UA
United Kingdom
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The Rapporteur's first Assessment Report was circulated to all CHMP members on 12
February 2013. The Co-Rapporteur's first Assessment Report was circulated to all CHMP members
on 9 February 2013.
During the PRAC meeting on 4-7 March 2013, the PRAC adopted an RMP Advice and
assessment overview.
During the meeting on 21 March 2013, the CHMP agreed on the consolidated List of
Questions to be sent to the applicant. The final consolidated List of Questions was sent to the
applicant on 25 March.
The applicant submitted the responses to the CHMP consolidated List of Questions on 23
July 2013.
The Integrated Inspection Report (IIR) of the inspections carried out at the following
site(s): Clinical Investigator sites in UK and USA, Sponsor site in USA and Central Pathology lab in
USA, between 2 April and 7 May 2013 was issued on 5 July 2013.
The Rapporteurs circulated the Joint Assessment Report on the applicants responses to
During the PRAC meeting on 2-5 September 2013, the PRAC adopted an RMP assessment
report.
During the CHMP meeting on 19 September 2013, the CHMP agreed on a list of
The applicant submitted the responses to the CHMP List of Outstanding Issues on 21
October 2013.
The Rapporteurs circulated the Joint Assessment Report on the applicants responses to
During the PRAC meeting on 4-7 November 2013, the PRAC adopted an RMP assessment
report.
During the PRAC meeting on 2-5 December 2013, the PRAC adopted an RMP Advice and
assessment overview.
During the CHMP meeting on 17 December 2013, outstanding issues were addressed by
During the meeting on 23 January 2014, the CHMP, in the light of the overall data
submitted and the scientific discussion within the Committee, issued a negative opinion for
granting a Marketing Authorisation to Translarna.
Martina Weise
Viktor Vlcek
The applicant submitted written notice to the EMA on 28 January 2014 to request a
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During its meeting on 17-20 February 2014, the CHMP appointed Martina Weise as
The applicant submitted the detailed grounds for the re-examination on 25 March 2014.
17 April 2014. The Co Rapporteur's Assessment Report was circulated to all CHMP members on 22
April 2014.
The Rapporteurs circulated the Joint Assessment Report on the applicants detailed
During the CHMP meeting on 19-22 May 2014, the detailed grounds for re-examination
were addressed by the applicant during oral explanations before the CHMP.
During the meeting on 19-22 May 2014, the CHMP, in the light of the scientific data
available and the scientific discussion within the Committee, the CHMP re-examined its initial
opinion and in its final opinion concluded that the application satisfied the criteria for authorisation
and recommended the granting of the conditional marketing authorisation.
2. Scientific discussion
2.1. Introduction
Duchenne muscular dystrophy (DMD) is a rare (1 in 3500 male newborns), disabling and ultimately
fatal X-linked genetic disorder that primarily affects males [Emery 1991, Worton 2001, Khurana
2003]. The disease is caused by mutations in the gene for dystrophin, a protein that is critical to
the structural stability of myofibers in skeletal, diaphragmatic and cardiac muscle and is also of
importance for the central nervous system and smooth muscles [Worton 2001, Khurana 2003].
DMD is caused by several types of mutations in the dystrophin gene such as deletions, insertions
and point mutations. Approximately 13% of patients with DMD have the disorder due to a
nonsense mutation [Dent 2005]. A nonsense mutation is a change in the nucleotide sequence of
DNA that is transcribed into a premature stop codon in the messenger RNA (mRNA) for dystrophin.
This stop codon causes the ribosome complex to terminate translation prematurely and results in a
truncated, non-functional protein.
The overall prevalence of DMD in the European Union (EU) is of the order of 0.37 per 10,000
[Orphanet 2011], accounting for approximately 18,600 individuals (current EU population
estimated at 503,500,000) [Eurostat 2012]. Based on the estimation that in about 13% of all DMD
patients the disease is due to a nonsense mutation (nmDMD) [Dent 2005], it is estimated that
there are approximately 2,400 patients with nmDMD in the EU.
The majority of genetic defects in subjects with Duchenne and Becker muscular dystrophy are large
deletions or insertions in the dystrophin gene. Point mutations leading to a nonsense codon are
relatively rare and are found in about 7-13% of the DMD/BMD patient population. In DMD the
disease is caused by the lack of a functional dystrophin - a structural protein from the sarcoglycan
complex important for stability of skeletal and cardiac muscle cell, but also expressed in the CNS
and smooth muscle. The concept of treating DMD subjects with a nonsense mutation is to promote
production of a full-length dystrophin protein and hence restore its function in muscle cells.
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There are no curative therapies available for DMD and the current management of the disease is
based on prevention and management of complications [Bushby 2010]. Corticosteroids (e.g.
prednisone or deflazacort) are the only pharmacologic therapy that have been demonstrated
to
temporarily reduce the decline in motor function in patients with DMD [Mendell 1989, Griggs 1991,
Fenichel 1991a, Fenichel 1991b, Biggar 2001, Beenakker 2005a, Biggar 2006, Pradhan 2006].
Ataluren is a first-in-class oral drug which is claimed to enhance ribosomal read-through of nonsense mutations in different genes. The mode of action of ataluren is believed to be related to the
ability of this compound to interfere with the ribosomal translational machinery in such a way that
premature nonsense stop codons in the mRNA are read through by the translational machinery and
this results in the translation of the entire mRNA and hence production of a full-length protein
product.
The applicant applied for the following indication:
Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a
nonsense mutation in the dystrophin gene, in patients aged 5 years and older (see section 5.1).
The presence of a nonsense mutation in the dystrophin gene should be determined by genetic
testing (see section 4.4).
The recommended dose of ataluren is 40 mg/kg/day, divided in 3 doses (10 mg/kg in the morning,
10 mg/kg at midday and 20 mg/kg in the evening) within 30 minutes of a meal.
13
C NMR, UV spectroscopy, IR
spectroscopy, mass spectrometry and elemental analysis. Physical properties were investigated
using DSC, TGA, XRPD, KF (to determine water content and hygroscopicity) and particle size
distribution.
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were provided. Additionally, stability data on six additional pilot scale batches of active substance
from a previous (no longer used) manufacturer stored in the intended commercial package for up
to 60 months under long term conditions at 25 C / 60% RH and for up to 6 months under
accelerated conditions at 40 C / 75% RH according to the ICH guidelines were provided as
supportive data. No changes to any of the measured parameters were observed over the course
of the studies under either long term or accelerated conditions.
The active substance was also exposed to thermal, humidity, photolytic, acidic, basic, and
oxidative stress conditions following ICH guideline Q1B. These studies further establish the
stability of Ataluren and demonstrate that the analytical methods are stability indicating.
The parameters tested are the same as for release with the omission of those unaffected by
storage (heavy metals, ROI and residual solvents) and the addition of microbial testing. The
analytical methods used were the same as for release.
The stability results indicate that the drug substance manufactured by the proposed suppliers is
sufficiently stable. The stability results justify the proposed retest period in the proposed
container.
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The primary packaging is child-resistant heat-sealed laminated aluminium foil sachets. The
material complies with Ph. Eur. and EC requirements. The choice of the container closure system
has been validated by stability data and is adequate for the intended use of the product.
Adventitious agents
No excipients derived from animal or human origin have been used in the formulation. Magnesium
stearate is derived from a vegetable source.
Manufacture of the product
The manufacturing process is considered standard for the production of granules. Key steps in the
process include roller compaction, milling and blending. Adequate process controls are in place for
each of these steps to ensure the quality of the finished product. The formal validation of the
process in the production facilities has not yet been completed but will be carried out prior to
release of Translarna to the market. A process validation scheme has been provided and the
applicant will validate the process before commercialisation.
Product specification
The finished product release specifications include validated tests for appearance (visual
description), identification (HPLC and UV), assay (HPLC), degradants (HPLC) content uniformity
(HPLC), dissolution (HPLC), water content (KF) and microbial limits (Ph. Eur.) appropriate for this
kind of dosage form.
Batch analysis results are provided for three batches of 125 mg strength, nine batches of 250 mg
strength and four batches of 1000 mg strength, confirming the consistency and uniformity of the
manufacturing process and its ability to manufacture the finished product to the intended
specifications.
Stability of the product
A bracketing strategy was used to investigate stability: the 125 mg and 1000 mg strengths were
tested but not the intermediate 250 mg strength. This is considered acceptable. Stability data
from three commercial scale batches of both 125 mg and 1000 mg strengths of finished product
stored under long term conditions (25 C / 60% RH) for 48 months, under intermediate
conditions (30 C / 75% RH) for 36 months at and for up to 6 months under accelerated
conditions (40 C / 75% RH) according to the ICH guidelines were provided. The batches of
Translarna were identical to those proposed for marketing and were packed in the primary
packaging proposed for marketing.
In addition, finished product in the proposed commercial packaging was exposed to light as
defined in the ICH Guideline on Photostability Testing of New Drug Substances and Products.
Samples were tested for appearance, assay, degradants, dissolution, moisture content, microbial
limits, granule particle size and average deliverable powder weight. The analytical procedures
used are stability indicating.
None of the parameters tested showed any observable trends over the course of the stability and
photostability studies.
Since finished product granules can be reconstituted in liquid media (water, milk, fruit juice) and
semi-solid media (yoghurt, pudding, apple sauce), in-use stability data have been provided which
indicate the preparation in water at ambient conditions or that in other liquid or semi-solid media
under refrigerated conditions should be used within 24 hours. The stability data also supports
transient excursion to room temperature for 3 hours in milk or yoghurt or 6 hours in fruit juice,
pudding, or apple sauce.
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Based on available stability data, the shelf-life and storage conditions as stated in the SmPC are
acceptable.
The applicant will conduct stability studies on the first 3 commercial production batches under
long-term (25 C / 60% RH) and accelerated (40 C / 75% RH) conditions, and 1 commercial
production batch per year thereafter.
2.3.2. Pharmacology
Primary pharmacodynamic studies
A series of in vitro studies were conducted in different model systems to characterise the primary
pharmacodynamics of ataluren. In HEK293 cells transfected with the luciferase gene engineered to
have premature stop codons at codon 190, increasing concentrations of ataluren resulted in dose-
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A dose-dependent readthrough and production of full-length, functional luciferase was also seen in
a cell-free translation assay (LUC-190 mRNA with a cytoplasmic translation extract from HeLa cells
(Fig. 2).
Fig. 2
In myotubes isolated from the mouse model of nonsense mutation DMD (mdx mice) testing
ataluren concentrations of 0.1 to 30 g/ml and in cultured human myotubes from nmDMD patients
testing concentrations of 0.1 to 40 g/ml, a bell-shaped dose response was observed, with
maximal induction of dystrophin at an ataluren concentration of 10 g/ml.
In mouse embryonic fibroblasts (MEFs) isolated from the mouse model of nonsense mutation
Hurler syndrome (Idua-W392X mice), reduction in tissue glycosaminoglycan levels due to
production of a full-length functional enzyme was evaluated. The maximal induction of enzyme
activity was seen at an ataluren concentration of 10 g/ml, indicating a bell-shaped response.
The ability of ataluren to read through premature stop codons, thus enabling production of full
length functional protein, was further investigated in vivo in nonsense mutation mouse models:
nmDMD mdx mice, Cftr-/- FABP-hCFTR-G542X mice (a mouse model of nonsense mutation cystic
fibrosis) and Idua-W392X mice (a mouse model of nmHurler syndrome).
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In the mdx mouse model of nmDMD testing three dosing regimens- oral, intraperitoneal (IP) and
combination of both, the optimal efficacy was observed with a combined oral and IP dosing (1.8
mg/ml via a liquid diet and 33 mg/kg IP TID). Pharmacokinetics were performed and this dosing
regimen resulted in a trough concentration of approximately 10 g/ml. Doses that would result in
higher plasma concentrations were not assessed and the potential for a bell-shaped response could
not be determined in this model. Overall, ataluren administration resulted in protection from
eccentric contraction injury and in reduced serum CK, indicating reduced muscle fragility.
Dystrophin was seen to be located in the cell appropriately, with levels accounting to 20% of the
normal levels.
During the procedure, the Applicant submitted additional data from an nmDMD zebrafish model
indicating promotion of nonsense mutation readthrough (fig. 3).
Fig. 3 Effect of ataluren treatment on dystrophin expression in nmDMD zebrafish model
Wild-type
untreated
ataluren
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Fig. 4
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2.3.3. Pharmacokinetics
The pharmacokinetic characteristics of ataluren were characterised after single- and repeat-dose
administration in mice. The toxicokinetics of ataluren were assessed after single- and repeat-dose
administration to animal species used in the toxicological evaluation, i.e. Tg.rasH2 wild type mice,
rats, dogs and rabbits.
Following oral administration of ataluren to mice, rats, dogs and rabbits, the drug was rapidly
absorbed and eliminated in all species, with peak concentrations after single doses occurring 0.25
to 4 hours post dose. The Tmax tended to increase with increasing dose and with multiple doses.
The half-life was similar across the non-clinical species tested and ranged within 1.1 to 7.6 hours.
There was no accumulation of drug in plasma upon repeated daily dosing. In rats, two peak plasma
concentrations were observed, indicating entero-hepatic recirculation. Plasma exposure to ataluren
in all species, based on Cmax and AUC, was less than dose proportional. After multiple dosing,
plasma exposure (in particular the AUC values) decreased after Day 1. Ataluren showed a high
plasma protein binding (98.4% in mouse, 98.7% in rat and 97.5 in dog).
Following intravenous administration of a single dose to dogs, the systemic clearance averaged 123
ml/kg.hr and the volume of distribution at steady state (Vss) was 0.21 l/kg. In a bioavailability
study conducted in dogs with intravenous and oral dosing, low bioavailability (7%) was seen, which
corresponded to the observed low urinary excretion in this species (12% of the dose). In mice and
rats, the excretion via urine and bile indicated high bioavailability (40% urinary excretion in mice
and 90% urinary and bile excretion in rats).
After oral administration of radio-labelled ataluren to rats, high concentrations were found in the
gastrointestinal tract, the secretion organs (liver and kidney), adrenal gland, brown fat and lung.
Low radioactivity concentrations were observed in the brain. The blood-to-plasma ratio of ataluren
radioactivity was less than one, indicating that ataluren does not accumulate in erythrocytes. At 24
hours after dosing, radioactivity was still observed in brown fat, skin and the Harderian and
preputial glands.
In rats, placental transfer of radio-labelled ataluren and excretion in milk were observed. At a
single maternal dose of 30 mg/kg, the concentration of foetal radioactivity was 27% of the
maternal concentration. At the same maternal dose, the highest measured concentration of
radioactivity in rat milk was 37% of the maternal plasma concentration. Presence of radioactivity in
pup plasma confirmed absorption from the milk by the pups. The composition of this radioactivity
(parent compound and/or metabolites) was not investigated.
The major biotransformation pathway of ataluren included acyl glucuronidation, reductive
oxadiazole ring cleavage, oxidative deamination and hydrolysis. In all species, unchanged ataluren
was the major component in plasma (ranging from 70 to 91%).
Ataluren was not metabolised by CYP isozymes, but was directly glucuronidated via UGT1A9 in
human liver microsomes. No non-clinical studies were performed by the applicant to evaluate
potential drug-drug interaction, but based on the in vitro data, inhibitors of UGT1A9 or drugs
metabolised by UGT1A9 may have a clinically relevant effect on the metabolism of ataluren.
In vitro studies indicated that ataluren was not a substrate for P-glycoprotein.
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Following a single oral dose of radio-labelled ataluren, the majority of the administered
radioactivity was excreted in faeces: 54% by mice, 84% by rats and 80% by dogs. Most of the
dose was excreted within 48 hours. The total recovery was >93% in the three species.
2.3.4. Toxicology
Single dose toxicity
Single dose toxicity studies of ataluren were conducted in rats and dogs. The oral LD50 in rats was
>2000 mg/kg, the highest dose tested. In an oral escalating dose study in dogs, ataluren was well
tolerated up to the highest dose of 1600 mg/kg. No macroscopic abnormalities were noted at
necropsy.
Repeat dose toxicity
Repeat dose toxicity studies of ataluren were conducted in mice for up to 29 days, in rats for up to
26 weeks and in dogs for up to 52 weeks. Both 26-week toxicology studies in rats and the 52-week
toxicology study in dogs initiated dosing in weanling animals to support dosing in children.
The major findings are summarised in Table 1.
Study
Species/Sex/
ID
Number/Group
Dose/ Route
Duration
NOEL/
Major findings
NOAEL
(mg/
kg/
day)
AB19L
A.2G3
R.04.B
TL
(GLP)
CByB6F1
(Tg.rasH2 nontransgenic
littermates)
hybrid mice
Main study:
Oral gavage
29 days
N/A
Final study:
29 day study:
1800: Hb (F), Hct (F), MCV (F), segm
neutrophils (F); Gluc (M), AP (M),
Creat (M)
0, 600, 1200,
or 1800
mg/kg/day
10 mice/sex/dose
and
44 mice/sex/dose
level for
toxicokinetics
Weanling (5 week
old) rats
36 (control and
high dose) and
24 (low and mid
dose)/sex/group
and
10/sex/group
(for
toxicokinetics)
Oral gavage
0, 150, 300,
or 1200
mg/kg/day
26 weeks
< 150
mg/kg/
day
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Study
Species/Sex/
ID
Number/Group
Dose/ Route
Duration
NOEL/
Major findings
NOAEL
(mg/
kg/
day)
and 2 M at 26 weeks and
150 mg group: 1M at 26 weeks)
150-300 mg/kg/day: body weight,
body weight gain
1144002
(GLP)
Weanling (4 week
old) rats,
22/sex/dose
and
Oral gavage
26 weeks
NOAEL
120
mg/kg/
day;
NOEL
30
mg/kg/
day
18/sex/dose
(for
toxikokinetics)
Dog
7470123
(GLP)
16/sex/dose (0,
1000 mg);
10/sex/dose
(250,500 mg).
Oral gavage:
0, 250, 500,
1000
mg/kg/day
52 week
with an 8week
recovery
period
Age at
start of
treatment:
68-83
days.
< 250
mg/kg/
day
Genotoxicity
Ataluren genotoxicity was evaluated in vitro in gene mutation tests in bacteria and in mammalian
cells and and in vivo in rat. The studies and their results are summarised in Table 2.
Table 2
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Carcinogenicity
Carcinogenicity potential of ataluren was tested in mice and rats. In a GLP-compliant 26-week
carcinogenicity study in Tg.rasH2 mice, ataluren did not increase the incidence of tumours up to
the highest doses tested in males (600 mg/kg/day) and in females (300 mg/kg/day). The nonneoplastic findings included endometrial hyperplasia and nephropathy in females. In a GLPcompliant 24-month carcinogenicity study in rats, urinary bladder tumours (benign urothelial cell
papilloma [2 rats] and malignant urothelial cell carcinoma [1 rat]) were seen in 3/60 female rats
dosed at 300 mg/kg/day. In addition, one case of malignant hibernoma was observed in 1/60 male
rats at the dose of 300 mg/kg/day. The non-neoplastic toxicity consisted of a decrease of body
weight.
Reproduction Toxicity
The package of reproduction toxicity studies consisted of a male/female fertility study in rats,
embryo-foetal developmental toxicity studies in rats and rabbits and a peri/postnatal toxicity study
in rats. In the fertility study, no effects on male/female fertility were observed at a dose of 300
mg/kg/day, the highest dose tested, and the NOAEL for early embryonic toxicity was the same as
in the rat embryo-foetal toxicity study. In the embryo-foetal toxicity study in rat, embryo-foetal
toxicity consisted of increased early resorptions, post-implantation loss and decreased viable
foetuses and signs of developmental delay (increased skeletal variations). The NOAEL for embryofoetal toxicity was 100 mg/kg/day, giving an exposure margin of factor 4 compared to human
exposure. The NOAEL for maternal toxicity was 30 mg/kg/day.
Placental transfer of ataluren and distribution in the rat foetus was investigated with radiolabelled
ataluren. At a maternal dose of 30 mg/kg/day, the concentration of foetal radioactivity was 1/3
of the maternal concentration.
In the rabbit embryo-foetal toxicity study, maternal and embryo-foetal toxicity was seen at the
highest tested dose of 100 mg/kg/day. Embryo-foetal toxicity consisted of decreased mean foetal
weight and increased skeletal variations. At the maternal and embryo-foetal NOAEL, there was no
exposure margin compared to human exposure.
In the rat pre/postnatal developmental toxicity study, significant effects on maternal food intake
and body weight and on offspring body weight and ambulatory activity were observed at a dose of
150 mg/kg/day, i.e. at an exposure 5 times higher than the human exposure. The maternal
systemic exposure at the NOEL for neonatal toxicity was <3 and at the LOEL <4.
Toxicokinetic data
The toxicokinetics of ataluren were characterised after single and repeated daily doses of 75-1800
mg/kg/day to mice (including the mouse carcinogenicity study), 30-2000 mg/kg/day in rats
(including the rat carcinogenicity study), 25-200 mg/kg/day in pregnant rabbits (in support of
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embryo-fetal development toxicology studies) and 200-1500 mg/kg/day in dogs. The toxicokinetic
data indicated a short t and also showed that there was no significant drug accumulation in
plasma upon repeated daily dosing. Ataluren exposure increased with increasing dose, but it was
less than dose proportional at higher doses. There were no sex-related differences in ataluren
exposure in dogs, but in rats and mice, exposure was slightly higher in females than in males. The
major metabolite seen in mice, rats and dogs was ataluren acyl glucuronide.
Local Tolerance
No local tolerance studies were performed (see section 2.3.6).
Other toxicity studies
No juvenile toxicity studies were performed (see section 2.3.6).
PBT-statement
Phase I
Calculation
PEC surfacewater , refined
(prevalence)
Other concerns (e.g. chemical
class)
Result
4.15 at
2.19 at
0.94 at
0.41 at
pH
pH
pH
pH
3.23
5.40
7.12
8.46
Conclusion
Not PBT
Conclusion
4.15
2.19
0.94
0.41
at
at
at
at
pH
pH
pH
pH
3.23
5.40
7.12
8.46
Not PBT
Unit
g/L
Conclusion
> 0.01 threshold
No
No
The maximal measured logKow of ataluren is 4.15 at pH 3.23) which is below the PBT screening
criterion of 4.5. A full PBT assessment has therefore not been conducted. The refined PECsurfacewater,
based on the prevalence of Duchenne muscular dystrophy (DMD) originating from nonsense
(premature stop codon) mutations (nmDMD) is calculated to be 0.0067 g/L, which is below the
threshold for progression to phase II ERA studies. It is concluded that Ataluren is not considered to
cause a potential risk to the environment.
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readthrough effect of ataluren on the premature stop codons under certain conditions, the CHMP
also considered recent publications, e.g. by Mc Elroy et al. 20131, which indicated a lack of
translational read-through activity for ataluren. The CHMP highlighted the conflicting nature of the
data available and the fact that the variability of results across test systems was not sufficiently
characterised. Nevertheless, it was concluded that the limited understanding of the variability in
the non-clinical setting would not be critical if sufficient clinical efficacy was shown.
The lack of readthrough of normal stop codons was supported by in vitro and in vivo studies.
Overall, the CHMP considered that the experimental data provided some reassurance that no
readthrough occurs at terminal stop codons level. Moreover, it was noted that a proteomic analysis
of HEK293 cells, treated and untreated with ataluren, will be performed by the applicant, in order
to further evaluate the potential of ataluren to promote readthrough of normal stop codons. The
CHMP recommended that these data should be submitted for review once available, as appropriate.
The bell-shaped dose response hypothesis (discussed further in the Clinical section) was supported
by data obtained from a number of in vitro test systems and in zebrafish larvae in ataluren
solution. Additional circumstantial evidence was obtained in in vivo models relevant for other
diseases. However, the CHMP considered that the bell-shaped curve was not seen in the in vivo
model of the DMD, i.e. the mdx mouse. Therefore, the applicants hypothesis that clinical efficacy
follows a bell-shaped dose-response curve was only partly supported by the non-clinical data.
Safety pharmacology studies were carried out in order to assess ataluren effects on the central
nervous system, respiratory system and cardiovascular system. No relevant effects on the CNS and
respiratory systems were observed in rats at doses up to 2000 mg/kg/day. Cardiovascular safety of
ataluren was assessed in vitro and in vivo. No relevant inhibition of ataluren on cloned hERG
channels expressed in mammalian cells was observed up to a free concentration of 100 M. The
results of in vivo studies in dogs assessing cardiovascular safety indicated that ataluren dosed up
to 1500 mg/kg did not elicit any biologically important changes in cardiovascular parameters.
The potential pharmacodynamic interactions of ataluren were explored. Of note, ataluren
readthrough effect was reduced in the presence of antibiotics known to interact with ribosomal
RNA. These studies suggested that there was no benefit to co-administration of systemic or inhaled
aminoglycoside antibiotics during treatment with ataluren and moreover, that the efficacy of
ataluren would be reduced during such co-administration.
The CHMP considered that the pharmacokinetics of ataluren were adequately characterised in the
non-clinical programme.
The applicant conducted an adequate toxicology programme for ataluren. All pivotal toxicity studies
were performed in compliance with GLP. Only the oral route of administration was investigated in
all tested species, which was considered acceptable by the CHMP.
The most important toxicity identified in mice after repeated dosing was nephrotoxicity. No NOEL
and no significant exposure margin compared to human exposure could be established. Although
this toxicity was not seen in the other species tested, i.e. rat and dog, since its mechanism in mice
is not known, the CHMP was of the view that its relevance for humans could not be ruled out.
One of the main concerns discussed was the finding of malignant hibernomas in rat. While this
finding was made only in this species, similarly to renal toxicity in mice, the CHMP concluded that
occurrence of similar effects in humans could not be excluded, particularly in the young population,
where the quantity of the brown adipose tissue is higher. In particular, the CHMP considered that
malignant hibernomas could be related to the effects of ataluren on fat tissue metabolism and to
effects on plasma lipid parameters, which were observed in rats, dogs and humans. Thus,
hibernomas were reflected in the proposed risk management plan of ataluren. The CHMP also
1
http://www.plosbiology.org/article/info:doi/10.1371/journal.pbio.1001593
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noted that the applicant will perform a 3 adrenergic binding assay with ataluren and one of its
metabolites to further investigate their potential effects in the brown adipose tissue in rats.
In addition to the above mentioned effects, several other less adverse effects were found in the
repeat dose studies; in particular decreased body weight gain, food intake and increased liver
weight without a histological correlate.
An adequate battery of genotoxicity tests was conducted and the data did not reveal any special
hazard for humans.
No evidence of carcinogenicity was seen in mice. In rats, cases of hibernomas were observed in the
carcinogenicity- and repeat dose toxicity studies. In addition, an increase of rare urinary bladder
tumours was found in rats, but the systemic exposure margin for these tumours compared to the
human exposure was considered sufficiently high and the finding hence of unlikely significance.
The CHMP considered that a GLP-compliant full reproductive toxicology programme consisting of
fertility and early embryonic development study, embryo/foetal development studies and a pre/postnatal development study was conducted.
The lack of formal local tolerance studies was considered acceptable by the CHMP, as ataluren is
intended for oral use and investigating the potential local gastro-intestinal effects was covered by
the oral repeated dose studies.
The CHMP considered that while no juvenile toxicity studies were performed, the repeated dose 26week rat studies started at the age of 4-5 weeks and the repeated dose 52-week dog study at the
age of 68-83 days. The CHMP was of the view that these studies were supportive of use in children
older than 4-5 years (based on the studies in rats) or slightly younger, 3-4 years (based on the
study in dogs). Overall, the CHMP concluded that the level of evidence available was, from the
perspective of non-clinical toxicity testing, sufficient to justify ataluren administration to patients 5
years and older, i.e. the patient population covered by the indication applied for.
ERA studies did not indicate potential risks to the environment linked to ataluren.
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2.4.2. Pharmacokinetics
Absorption
Although ataluren is practically insoluble in water, it is readily absorbed after oral administration as
a suspension. Ataluren was rapidly absorbed with Tmax between 0.5 and 2.5 h after single doses in
fasted adult healthy volunteers. Peak plasma levels were attained approximately 1.5 hours after
dosing in subjects who received medicinal product within 30 minutes of a meal. Based on the
urinary recovery of radioactivity in a single-dose study of radiolabeled ataluren under fasting
conditions, the oral bioavailability of ataluren was estimated to be 55%.
The effect of food on ataluren bioavailability was investigated in study 001, using a formulation
(powder in bottle) different from the phase 2a/2b formulation. Based on PK modelling in healthy
volunteers and data from patients with nmDMD, no significant effect of food was detected on either
the rate or extent of ataluren absorption.
Ataluren plasma concentrations at steady state were dose-proportional for ataluren doses between
10 and 50 mg/kg. No accumulation was observed after repeated dosing.
Distribution
In vitro, ataluren was 99.6% bound to human plasma proteins and the binding was independent of
plasma concentration. Ataluren did not distribute into red blood cells.
Ataluren volume of distribution (Vz/F) varied between 393 and 689 l when single doses between 3
and 200 mg/kg were administered in healthy volunteers. A lower volume of distribution (around 50
l for a 70 kg adult) was determined in the population pharmacokinetic analysis.
Elimination
In vitro, ataluren was metabolized by conjugation via uridine diphosphate glucuronosyltransferase
(UGT) enzymes, predominantly UGT1A9 in liver and intestine. Cytochrome P450 system was not
involved in the metabolism of ataluren.
In vivo, the only metabolite detected in plasma after oral administration of radio-labelled ataluren
was the ataluren-O-1-acyl glucuronide; exposure to this metabolite in humans was approximately
8% of the plasma AUC of ataluren.
Ataluren plasma half-life ranged from 2-6 hours and was unaffected either by dose or repeated
administration. The elimination of ataluren was likely dependent on hepatic and intestinal
glucuronidation of ataluren followed by renal excretion of the resulting glucuronide metabolite.
After a single oral dose of radiolabeled ataluren, approximately half of the administered radioactive
dose was recovered in the faeces and the remainder was recovered in the urine.
In the urine,
unchanged ataluren and the acyl glucuronide metabolite accounted for <1% and 49%,
respectively, of the administered dose.
Dose proportionality and time dependencies
In study 001 conducted under fasting conditions, more than a dose proportional increase in AUC0-
of ataluren was observed over the studied dose range, i.e. 3mg/kg to 200 mg/kg. In study
PTC124-GD-002-HV under fed conditions, dose proportional increase in AUC and Cmax was seen
for ataluren between doses 10 and 50 mg/kg. After BID dosing for 7 days, plasma exposure of
ataluren increased also in a more than dose-proportional manner. In healthy volunteers, after BID
dosing of 50 mg/kg for 14 days, plasma ataluren concentrations appeared to decrease over time
with the linearity factor decreasing to 0.6, suggestive of non-linear PK at 50 mg/kg dose in this
study. Data from clinical trials on plasma concentration indicated that the steady state is
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maintained from Week 6 (the earliest measurement time) through more than two years of
treatment and based on the proposed popPK analysis it was estimated that 95% of the decrease to
the steady-state value occurs within the first two weeks of therapy.
Special populations
Age
Based on data from subjects ranging in age from 5 years to 57 years, there was no apparent effect
of age on ataluren plasma exposure.
Gender
Females were not studied in nmDMD clinical trials.
Caution should be exercised when ataluren is co-administered with drugs that are
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Furthermore, based on in vitro studies, ataluren was not expected to be an inhibitor of either p-gp
mediated transport or of cytochrome P450 mediated metabolism.
interaction
between
ataluren
and
corticosteroids
was
investigated
by
analysing
usage
in
the
long-term
studies
in
nmDMD
patients.
Coadministration
corticosteroids with ataluren did not affect the plasma concentrations of ataluren.
of
No clinically
relevant change in the plasma concentrations of corticosteroids was seen with co-administration of
ataluren.
2.4.3. Pharmacodynamics
Mechanism of action
Ataluren was claimed to enable ribosomal readthrough of mRNA containing a premature stop
codon, resulting in production of a full-length protein (dystrophin). A premature stop codon within
an mRNA is a result of a nonsense mutation in DNA and causes disease by terminating translation
before a full-length protein is generated. A nonsense mutation is an underlying genetic defect in
approximately 13% of DMD patients.
because
they
do
not
have
disease-causing
premature
stop
codons.
Therefore,
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was sampled pre- and post-treatment to improve the ability to quantify dystrophin expression.
61% of patients showed an increase in dystrophin staining in 28 days of ataluren treatment. A
mean change from baseline to Week 4 of 11.0% in dystrophin expression was observed in the
overall study population (p=0.008, paired t-test comparing pre-treatment to post-treatment). The
mean per cent change in dystrophin expression was generally similar across the dose levels (4, 4,
8 mg/kg [n=6]; 10, 10, 20 mg/kg [n=20]; 20, 20, 40 mg/kg [n=10]) and no clear dose-response
relationship was observed, which was attributed by the Applicant to the small and unequal
numbers of patients in each group and the short duration of the study.
Muscle biopsies were also collected in the pivotal Study 007, which had a treatment period of 48
weeks. In this study, biopsy of the biceps brachii was performed from one arm at baseline (pretreatment sample) and from the other arm at Week 36 14 days (post-treatment sample) to
assess the production of dystrophin. Based on a quantitative analysis of patients with pre- and
post-treatment muscle biopsy samples, a mean change (from pre-treatment to post-treatment) of
2.8% in dystrophin expression was observed in the ataluren 10, 10, 20 mg/kg dose group, 1.3% in
the ataluren 20, 20, 40 mg/kg dose group, and 0.09% in the placebo group. These differences
were not statistically significant.
The analysis of muscle dystrophin expression in Study 007 was compromised by limitations in the
available assay methods to sensitively measure changes in dystrophin expression at low levels and
by poor sample quality in the majority of muscle biopsy samples (primarily due to artefacts
introduced in the handling and shipping of the samples). Only 19 (~11%) paired pre- and posttreatment biopsy samples met the criteria of an optimal sample, defined as no or mild freeze
artefact, good cross orientation and no more than mild or moderate fibrotic replacement. Of these
19 optimal paired samples, there were similar positive and negative changes in dystrophin
expression across all 3 treatment groups.
Other evidence of ataluren s pharmacologic action was provided from the open-label Phase 2
studies of ataluren in paediatric, adolescent and adult patients with nmCF. This disease is caused
by nonsense mutations in the gene for the cystic fibrosis transmembrane conductance regulator
(CFTR). In these studies, the activity of ataluren to restore CFTR in nmCF patients was supported
by improvements of transepithelial potential difference, which directly measures CFTR function in
the nasal mucosa.
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The CHMP considered that the data on dose- and time linearity/non-linearity were inconclusive, but
the clinical trial data suggesting that the steady state is maintained from week 6 through more
than two years of treatment were re-assuring.
With respect to special populations, the CHMP was of the view that age-adjusted dosing would not
be required and that the data available on patients of other than Caucasian population were limited
to allow any conclusions regarding use in different ethnic groups. In the absence of specific studies
in patients with renal or hepatic impairment, the CHMP considered the pharmacokinetic properties
of ataluren. As it is extensively metabolized in liver and renal excretion accounts for 50% of the
drug elimination, hepatic and renal impairment can be expected to result in ataluren/ataluren
glucuronide accumulation. The CHMP concluded that close monitoring would be required in clinical
practice, should these patients be treated. Furthermore, additional studies addressing the
pharmacokinetics and safety in these patients were considered necessary, as described in the
proposed Risk Management Plan.
The CHMP discussed the interaction potential of ataluren and was of the view that this should be
further explored by the Applicant. Of note, as ataluren was shown to inhibit UGT1A9 in vitro, the
CHMP requested that in vivo studies with a sensitive probe substrate be conducted. Furthermore,
because of the observed time dependency, interaction study with UGT1A9 inducer should be
performed. Since ataluren may be expected to inhibit OAT1, OAT3 and OATP1B3 in vivo, in vivo
studies with sensitive probe substrates for these transporters were also deemed necessary. The
CHMP also considered that in vitro studies showed that ataluren was a substrate of BCRP and
consequently requested that the potential interactions between ataluren and a BCRP selective
inhibitor should be evaluated also in an in vivo study.
In order to characterise the mechanism of action of ataluren, a series of studies were conducted in
vitro and in vivo, as detailed in the non-clinical section. While the CHMP acknowledged that the
data from the presented studies were supportive of the readthrough ability of ataluren, recent
literature provided some evidence indicating lack of translation readthrough, rendering the
Applicants
data
less
convincing.
Furthermore,
the
CHMP
questioned
whether
the
oral
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In the context of these data, the CHMP concluded that the pharmacodynamic effect of ataluren, i.e.
production of dystrophin in muscle cells of DMD patients treated with ataluren, could not be
considered confirmed. Secondly, even if dystrophin were produced in cells with advanced stage of
fibrosis, it could be questioned whether newly produced dystrophin may restore the disrupted
sarcoglycan complex which plays a role in muscle fibre stability and protection from damage.
Examples from other clinical studies with products inducing dystrophin production in muscle cells
indicated that this may not translate into convincing clinical efficacy. Overall, the lack of a
pharmacodynamic effect in study 007 was considered a weakness of the dossier and is also limiting
the external validity of the efficacy results.
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Phase 2a DMD study (Study 004) for 28 days. Collectively, these considerations supported
inclusion of the 20-, 20-, 40-mg/kg dose level in the Phase 2b study.
The 10, 10, 20 mg/kg dose tested in Study 004 showed clinical pharmacodynamic activity and,
unlike the 4-, 4-, 8-mg/kg dose level, achieved trough exposure levels within the target range of
2 to 10 g/mL associated with activity in nonclinical models. The Cmax and AUC0-24 values
associated with this dose level suggested favourable exposure ratios relative to animal
toxicokinetic data. Clinically, these exposures were safe across the Phase 2a DMD and CF
experience. For these reasons, the 10, 10, 20 mg/kg dose level was also evaluated in the Phase
2b study.
of
DBMD,
serologic
evidence
of
hepatitis
or
and
change
in
prophylaxis/treatment for congestive heart failure within 3 months prior to start of study
treatment. Patients receiving corticosteroid therapy were required to have stabilization of such
therapy prior to study entry.
Treatments
Patients received placebo, ataluren 10, 10, 20 mg/kg (total daily dose 40 mg/kg) or ataluren 20,
20, 40 mg/kg (total daily dose 80 mg/kg) every day during the treatment period using a TID
schedule comprising morning, midday and evening doses. Approximate intervals for dosing were
to be 6 hours between morning and midday doses, 6 hours between midday and evening doses
and 12 hours between the evening dose and the morning dose on the next day.
Administration within 30 minutes after a meal was recommended. Study drug dosing was based
on milligrams of drug per kilogram of body weight. The planned duration of treatment was 48
weeks.
The use of corticosteroids was to be standardized as much as possible during the study in order to
minimize potential confounding effects. In patients not on corticosteroids at the beginning of the
study, initiation of corticosteroid therapy during the study was discouraged unless there was a
strong medical need. For patients on corticosteroids at the beginning of the study, a stable
corticosteroid regimen was to be maintained during the study. Adjustments in corticosteroid
dosage for increases in body weight were permitted but were not mandatory.
Objectives
The primary objective was to determine the effect of ataluren on ambulation.
The secondary
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study drug treatment and ataluren plasma exposure were also assessed.
Outcomes/endpoints
The primary efficacy endpoint was change in 6MWD from baseline to Week 48. The secondary
endpoints comprised changes in proximal muscle function as assessed by timed function tests;
change in force exerted during knee flexion and extension, elbow flexion and extension and
shoulder abduction as assessed by myometry; change in activity in the community setting as
assessed by step activity monitoring; change in the patient-reported wheelchair use; change in
patient and parent/caregiver reported HRQL as measured by the Pediatric Quality of Life
Inventory (PedsQL); change in parent/caregiver-reported treatment satisfaction as measured by
the Treatment Satisfaction Questionnaire for Medication (TSQM); change in the rate of accidental
falls per day as recorded by patients and/or parent/caregivers in a daily diary; change in verbal
memory and attention as assessed by the digit span task; change in heart rate before, during,
and after each 6MWT as assessed by heart rate monitoring; change in serum concentration of CK;
and change in biceps muscle dystrophin expression as determined by immunofluorescence.
The safety endpoints were the type, frequency, severity, timing and relationship to study drug of
adverse
events,
laboratory
abnormalities,
vital
sign
changes,
electrocardiogram
(ECG)
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Statistical methods
A mixed-model repeated-measures (MMRM) analysis of the change in 6MWD from baseline to
Week 48 was performed in the intent-to-treat (ITT) population (all randomized patients with a
valid 6MWT at baseline and 1 post-baseline visit). Included in the model were treatment,
baseline 6MWD, age (<9 or 9 years), corticosteroid use (yes or no), visit, and treatment-by-visit
interaction. Because baseline 6MWD was included in the model as a covariate, the stratification
factor of baseline 6MWD was excluded from this model. Least-squares means and variance
estimates of changes in 6MWD at Week 48 were generated from the model. These estimates were
then used to compare the changes in 6MWD at 48 weeks between each ataluren treatment arm
and the placebo arm. Normality was tested using the Shapiro-Wilks W-test at the 0.05
significance level. Because a significant degree of non-normality was observed, rank-transformed
data were used in the pre-specified analysis.
Sensitivity analyses were performed to assess the potential for induction of bias due to lack of
patient conformance to the protocol, inclusion of sibling pairs, and missing data (analysis after
multiple imputation and last observation carried forward [LOCF]) and dynamic randomization in
an MMRM setting (permutation test). A sensitivity analysis to assess robustness of the primary
efficacy results to missing data was based on the LOCF concept, by applying an analysis of
covariance (ANCOVA) model to the last available post-baseline 6MWD observation, with
covariates as defined in the SAP.
As specified in the SAP, time to persistent 10% 6MWT worsening (last time that 6MWD was not
10% worse than baseline) and time to persistent 10% 6MWT improvement (last time that 6MWD
was not 10% improved over baseline) were evaluated as supportive analyses of the primary
endpoint. Differences between each ataluren treatment arm and the placebo arm were assessed
using Kaplan-Meier methods and the stratified log-rank test.
In general, secondary variables were analysed using the final MMRM that was used for the
primary analysis of the 6MWD data, except that the baseline value of the secondary variable of
interest served as the covariate and baseline 6MWD was added to the model as an independent
variable. In cases where an MMRM analysis was not appropriate for the secondary variable of
interest, alternative statistical methods were used as necessary.
Post-hoc:
Post-hoc refined MMRM, including baseline-by-visit interaction term, analysis of 6MWD as well as
stair-climbing, stair-descending, running/walking 10 meters, and rising from supine to stand were
performed in the corrected ITT population. It was recognized after unblinding that 2 patients had
baseline 6MWTs that were incorrectly classified as valid. In fact, these 2 patients suffered from
recent lower leg injuries that reduced their baseline 6MWD when compared to their prior 6MWD at
Screening or subsequent 6MWD at Week 6. These 2 patients should not have been included in the
ITT population without a valid baseline test. To address this issue their baseline values were
replaced with screening values, creating a corrected ITT population.
Results
Participant flow
The study participant flow is shown in figure 6.
Fig. 6
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Recruitment
The study took place between 28 February 2008 (first patient first visit) and 17 December 2009
(last patient last visit).
Conduct of the study
The most common protocol deviations involved variations from protocol-specified collection times
for safety and efficacy assessments, particularly laboratory evaluations (urinalysis, haematology
and blood chemistries). Patients who did not have an evaluation that was needed for a particular
statistical analysis (e.g. missing baseline data in evaluations of change from baseline) were
excluded from that analysis. With regard to eligibility, seven of the 174 patients had laboratory
abnormalities at screening that should have excluded their participation in the study. However, a
decision had already been mad to amend the protocol to allow for inclusion of patients with
clinically insignificant laboratory abnormalities and thus, waivers were granted allowing these
patients into the study and the planned protocol amendment was subsequently implemented.
None of the patients received excluded concomitant medication and no patients were withdrawn
from the study due to developing any of the withdrawal criteria (as assessed by the adverse
event data).
Baseline data
A summary of the patient population enrolled in the study is presented in the tables below:
Table 5 Patient demographics
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Numbers analysed
Available data for all 57 patients who received placebo, 57 patients who received ataluren 10, 10,
20 mg/kg and 60 patients who received ataluren 20, 20, 40 mg/kg were included in analyses of
efficacy. The only patients excluded from all analyses of efficacy were those who failed screening
(see fig. 7 above).
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Further results of the pre-specified efficacy analysis in the ITT population, i.e. analysis of the
change in 6MWD at Week 48 is presented in table 8 below.
Table 8 Pre-specified MMRM analyses of change in 6MWD (ITT)
The observed difference between the ataluren 10, 10, 20 mg/kg and placebo arms in mean
change in observed 6MWD from baseline to Week 48 was 29.7 meters (Figure 8).
Figure 8, Mean change in observed 6MWD by Visit (ITT)
A post hoc statistical analysis was performed on the cITT population (see section Statistical
methods) and presented by the Applicant to support the efficacy of ataluren. The observed
difference in the mean change in the 6MWD from baseline to Week 48 between placebo and the
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lower dose of ataluren (10, 10, 20 mg/kg) was 31.3 metres, while the
difference was 31.7
model-estimated
observed between the higher dose (20, 20, 40 mg/kg) and placebo. The results are shown in
figure 9 and table 8 below).
Fig. 9 Mean change in observed 6MWD by visit (cITT)
Change in observed 6MWD (mean SEM, m)
20
10, 10, 20 dose vs Placebo
Week 48 = +31.3 m
10
0
-10
-20
31.3 m
-30
10, 10, 20 dose (N=57)
-40
-50
Placebo (N=57)
-60
Baseline
12
18
24
30
36
42
48
Time (weeks)
Table. 8. Post Hoc MMRM Analysis of Change in Untransformed 6MWD based on Permutation test
(Corrected ITT).
As pre-specified, the proportions of patients with at least 10% worsening in 6MWD at Week 48
were assessed. At Week 48, 44% and 48% of patients in the placebo and 20, 20, 40 mg/kg
ataluren arms, respectively, were progressors, with no statistically significant difference between
these arms. In the 10, 10, 20 mg/kg ataluren arm, 26% of patients were progressors (nominal
p=0.0326, adjusted p=0.0652).
The hazard ratio for ataluren 10, 10, 20 mg/kg vs placebo was 0.51 representing a 49% reduction
in the risk of 10% 6MWD worsening.
Fig. 10 Time to persistent 10% 6MWD worsening (cITT)
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Secondary outcomes
Timed function tests
The results on timed function tests of muscle function (table 9) indicated positive trends for
climbing and descending four stairs and running/walking 10 metres, as evidenced by less decline
over 48 weeks; these differences were more prominent in the lower dose. No difference between
ataluren and placebo was observed for the stand to supine test.
Table 9 Timed function tests and functional method scores (cITT)
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Wheelchair use
Patient-reported wheelchair use showed a positive trend favouring ataluren 10, 10, 20 mg/kg vs
placebo. Mean percentage of day of wheelchair use (95%CI) increased from baseline to Week 48
by 11.5% (4.36, 18.54) for placebo, 4.0% (-2.77, 10.68) for ataluren 10, 10, 20 mg/kg and 9%
(0.7, 17.38) for ataluren 20, 20, 40 mg/kg. The treatment differences were not statistically
significant.
Frequency of accidental falls
Over 48 weeks, reductions in the frequency of accidental falls were seen at both dose levels
compared to placebo. The absolute numbers showed a decrease from baseline to Week 48 of 0.04 falls per day in the 10, 10, 20 mg/kg ataluren arm vs increase of 0.18 falls per day in the
placebo arm (table 12).
Table 12 Change in falls/day
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Treatment arm
Falls/Day (SD)
Baseline
Week 48
Placebo
0.54 (0.94)
0.72 (1.28)
0.27 (0.48)
0.23 (0.53)
0.40 (0.60)
0.28 (0.53)
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This figure shows that patients younger than 7 years tend to increase their 6MWD over 48 weeks
(maturational improvements). Patients who have higher baseline 6MWD (above 350 m) tend to
be stable over the 48-week period, whereas those patients with lower baseline 6MWD (below 350
m) show decline in their walking ability over 48 weeks.
Based on the natural history data, the applicant considered that the ability to measure a
treatment effect over a shorter period (48 weeks) would be greater in the decline-phase patients
(7-16 years, baseline 6MWD 150 metres and <80% of predicted 6MWD). This was reflected in
the design of the planned confirmatory phase 3 trial (inclusion criteria) as well as in the decline
phase subgroup analyses of the primary and secondary endpoints of study 007 (fig. 12 and fig.
13).
Figure 12 Mean change in the observed 6MWD by visit (decline phase subgroup)
Fig. 13 TFT results in the phase 2b overall population vs decline phase subgroup
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Figure 14 presents the activity of ataluren observed in patients at different ambulatory stages,
categorised based on %-predicted 6MWD at baseline, indicating a favourable effect of ataluren
across the disease spectrum, including milder patients (i.e. baseline values above 70% predicted
6MWD).
Fig. 14 Response by category of ambulatory capacity
Furthermore, evidence of a correlation between the plasma concentration achieved and the effect
in terms of 6MWT and TFTs was presented by the Applicant to support the robustness of the effect
of the selected dose (fig. 15) and a scatter plot with change in 6MWT and plasma concentration on
an individual patent level (fig. 16).
Fig. 15 Inverse concentration response in clinical data: Phase 2b study
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-20
-40
-60
6
6MWD
Climb
Descend
10m W/R
Hypothesis
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multicenter, international, randomized (1:1:1), double-blind, placebocontrolled, dose-ranging study, stratified by age, corticosteroid use and
baseline 6MWD
Duration of main phase:
48 weeks
Duration of screening phase:
n.a.
Superiority
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Treatments groups
Placebo
Ataluren 10-10-20 mg/kg
Ataluren 20-20-40 mg/kg
Endpoints and
definitions
Primary
endpoint
6MWD
Analysis population
and time point
description
Descriptive statistics
Placebo
Number of
subjects
Baseline
57
57
60
359.5 (87.7)
350.0 (97.6)
358.2 (104.0)
Change in
observed 6MWD
Mean (SD)
Median
Min, max
The modelestimated
difference in
mean change in
untransformed
6MWD at Week
48
the modelestimated
difference in
mean change in
untransformed
6MWD at Week
48
-41.8 (89.2)
-12.9 (72.0)
-42.6 (90.1)
-36.0
-0.5
-17.0
-299.0, 172.1
-248.5, 123.1
-314.5, 127.2
Comparison groups
Ataluren 10-10-20 mg/kg
vs Placebo
Difference (meters)
26.4
95% CI
-4.2, 57.1
p-value
nominal -0.0905
adjusted 0.1592
Comparison groups
Difference (meters)
95% CI
-30.4, 30.2
p-value
nominal - 0.9956
adjusted 1.0000
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No studies in patients with renal or hepatic impairment were performed (see the Clinical
pharmacology discussion, section 2.4.4).
Supportive studies
With the exception of the pivotal 007, all studies presented in the dossier were conducted as
uncontrolled:
PTC124 GD 004 DMD (as Study 004) - an open-label Phase 2a trial assessing 3 dose levels of
Translarna (4, 4, 8 mg/kg; 10, 10, 20 mg/kg; and 20, 20, 40 mg/kg) evaluating muscle
dystrophin expression as the primary endpoint.
The results of study 004 are summarised and discussed in the Clinical Pharmacology section
(2.4).
PTC124 GD 004e DMD (Study 004e) - an open-label Phase 2a extension trial assessing Translarna
20, 20, 40 mg/kg
PTC124 GD 007e DMD (study 007e) - an open label Phase 2b extension trial assessing Translarna
20, 20, 40 mg/kg
PTC124 GD 008 DMD, referred to as Study 008 - an open-label Phase 2a trial assessing
Translarna 20, 20, 40 mg/kg
After unbinding of study 007 and the observation of no separation of the high dose from placebo,
studies 004e, 007e and 008 were some prematurely stopped since patients were treated with the
20/20/40 mg/kg dose.
Two open-label studies were ongoing at the time of this marketing authorisation application:
PTC124-GD-016-DMD (Study 016) - an open-label Phase 3 safety trial of ataluren in ambulatory
and non-ambulatory patients who originally participated in Studies 007, 007e, 004, 004e or 008.
Patients were treated with ataluren 10, 10, and 20 mg/kg for an open duration.
PTC124-GD-019-DMD (Study 019) - an open-label Phase 3 safety trial of ataluren in ambulatory
and non-ambulatory patients who originally participated in Studies 007 and 007e Patients were
treated with 10, 10, and 20 mg/kg for 48 weeks.
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years and the age range of recruited subject ranged from 5 to 20 years) and patients with DMD
as well as BMD could be enrolled, the population was rather heterogeneous. Furthermore, as the
study included only ambulant boys, since the primary endpoint was the 6MWT, the CHMP
considered that extrapolation of efficacy results to the entire DMD patient population might be
difficult.
The applicant provided a justification as to why the 6MWT is considered the most appropriate and
relevant measurement tool for DMD and for the objectives of the study. The CHMP acknowledged
that the 6MWT is one of the most commonly applied tools for this condition and that ambulation is
a very important aspect for individuals affected by the disease. However, as discussed in
literature, the 6MWT has in itself several deficiencies, such as high inter- and intra-individual
variability. Furthermore, the results can be influenced by several factors, e.g. behaviour,
motivation, fatigue and a learning effect. Therefore, the CHMP highlighted during their follow-up
protocol assistance that clinically meaningful effects should be seen in the domains of disability
and muscle strength. Since the study was already performed with the 6MWT as the only primary
endpoint, the CHMP pointed out in this protocol assistance that the outcomes of the timed
functional tests, myometry and the other secondary endpoints should be supportive of efficacy,
i.e. pointing in the same direction.
The 48 week duration of the clinical trial was in general considered adequate to investigate the
efficacy of the test product. Still, based on the data available (and discussed below), the CHMP
noted that the ability to measure a treatment effect in 1 year was lower in patients with stable
ambulatory ability, as compared to the population of patients in the decline phase of ambulation,
which might have impacted the efficacy observed in the overall population of the study.
With respect to GCP compliance and data verification, a routine inspection and an additional
inspection requested by CHMP were performed. The inspections were conducted at the sponsor
site, two clinical investigator sites and at the central pathology laboratory where the biopsies were
analysed. The main findings pertained to archiving, AE reporting, lack of oversight (at the
investigator sites); lack of oversight and QC/QA issues (at the sponsor site) and limited GCPawareness regarding documentation and archiving (at the laboratory). With respect to the
acceptability of the clinical trial data, the inspection team considered that the data presented in
the clinical study reports were reliable and suitable for assessment in the MAA.
Efficacy data and additional analyses
The primary analysis of the data resulted in a difference of -0.1 m (95% CI -30.4, 30.2; nominal pvalue= 0.9956, adjusted p-value=1.0000) between placebo and the high dose arm and a
difference of 26.4 m (95% CI -4.2, 57.1; nominal p value=0.0905, adjusted p-value = 0.1592)
between placebo and the low dose arm. As the results were not statistically significant, the study
007 was formally considered negative. Two subjects had invalid baseline measurements; analyses
with these invalid baseline data, without these subjects or with corrected baseline values were
performed to assess the impact of different approaches. P-values varying between 0.05 and 0.09
were observed, with sometimes substantially overlapping confidence intervals in the different
analyses, but comparable results in terms of point estimates (25-35m) were seen. Taken together
with the fact that the variation in 6MWD turned out to increase over visits and exceeded the
variation accounted for in the sample size calculation, the lack of statistical significance was
assumed to be a consequence of under-powerment of the trial. Overall, the effect was considered
consistent, but the confidence intervals were too wide to be perceived as conclusive.
Further analyses and discussions were made on the corrected ITT population (cITT), which from a
methodological point of view might be considered acceptable, although the CHMP flagged the fact
that the results were post-hoc derived. In the post-hoc analysis of the primary endpoint, the
10/10/20 mg/kg group had an observed mean of 31.3 meters less deterioration on the 6MWT, as
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compared to the placebo group, while the 20/20/40 mg/kg group was not distinguishable from
placebo. The model-estimated mean showed a value of 31.7 m (95 % CI 5.1,58.3) with a nominal
p value= 0.0281 and an adjusted p value = 0.0561. The CHMP also considered the results of a
progressor analysis which was discussed during the protocol assistance and which showed that the
proportion of subjects with 10% deterioration on the 6MWT (indicating disease progression) at
week 48 was 26% in the low dose group versus 44% in the placebo and 48% in the high dose
group.
To further support the robustness of the efficacy data the applicant was requested to discuss the
outcomes on the secondary endpoints, particularly on the timed function tests and patient reported
quality of life outcomes. The results indicated trends towards better outcome on some endpoints,
e.g. 4 stair ascend, 4 stair descend, 10-m run/walk, smaller increase in time at the end of the
study was seen in the ataluren arms as compared to placebo. These differences were more
pronounced in the low dose group, but being expressed in (mili)seconds were difficult to interpret.
The frequency of patient/parent-reported accidental falling was also considered a relevant endpoint
by the CHMP, since it is related to limb fractures which further reduce the activity and may
accelerate the transition to permanent loss of ambulation. Moreover, the fact that this endpoint did
not highly correlate with the 6MWT indicated that the rate of falls is measuring a different activity
than the 6MWT. Since accidental fall rate was included in the study protocol as a secondary
endpoint, it was surprising that a rather high number of subjects had no baseline values. On
request of the CHMP the absolute figures were presented indicating that the low dose arm had
milder (on this parameter) subjects (0.27 falls/day) as compared to placebo (0.54) and high dose
arm (0.40). The absolute rates of accidental falls indicated that the population in the low dose arm
was milder in this respect. Therefore, the data on
baseline to Week 48 of -0.04 falls per day in the 10, 10, 20 mg/kg ataluren arm, vs an increase of
0.18 falls per day in the placebo arm) were not considered as indicating a true effect of ataluren
on this parameter.
With respect to the mean percentage of wheelchair use, the CHMP considered the baseline data
and the respective increases observed in each treatment groups at week 48 and requested
additional information on the way the wheel chair use was registered. As the questionnaire did not
take into account total duration of use of a wheelchair, but only a day in which it was used, it was
considered that the variability in performance and the actual need for use of a wheelchair could not
be completely captured.
The data from the step activity monitoring indicated less increase in time spent in no activity in the
10/10/20 group, but the results were considered inconclusive. The clinical relevance of spending
2% less of the time in no activity was not substantiated.
The CHMP paid specific attention to evaluation of muscle strength, which is considered as an
important outcome for this disorder. Over 48 weeks, ataluren-treated patients generally showed
less decline in muscle strength, as evidenced by smaller decreases in most myometry parameters
relative to placebo. However, observed differences were considered to be below the level of clinical
meaningfulness. The CHMP considered the applicants argumentation that in the course of the
disease there is severe disorganisation within the muscle (at the level of muscle fibres and fibre
bundles) as well as fibrosis and aberrant innervation. Thus, in case of new production of functional
dystrophin the regeneration processes and restoration of muscle strength may indeed be time
consuming and may not be seen in a study of a shorter duration. Furthermore, as indicated by the
SAG Neurology experts, while minimal increase in dystrophin production could lead to functional
improvement, much higher levels of dystrophin in muscular fibres would have to be achieved for an
effect on strength to be seen. In this context, i.e. little supportive evidence of effect on muscle
strength, the CHMP considered that robust and convincing results on the functional outcomes
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(6MWD and functional timed tests) are of even greater importance and in the absence thereof, the
entire body of evidence of efficacy is considered weak.
Overall, the CHMP considered that the results on the secondary endpoints did not support the
primary endpoint. The view that there was little supportive evidence of effect from the data on the
secondary endpoints was also shared by the SAG Neurology experts.
In an additional post-hoc analysis of a subgroup of patients in the decline phase (older than 7
years, treated with corticosteroids, baseline 6MWD 150 metres and <80% predicted 6MWD) a
difference in mean 6MWD of -50 metres was seen, favouring ataluren 10, 10, 20 mg/kg. This result
was considered to be a clinically meaningful improvement in terms of stabilisation of walking. A
similar effect was also consistently observed in the key secondary endpoints, i.e. time function
tests, which provided reassurance to the global results. The applicant discussed this finding making
reference to the natural history data on 6MWD in DMD patients and concluded that over a shorter
period of time, subjects in the decline phase of their walking ability may show a greater effect than
patients with stabilised ambulation. At the same time, the applicant argued that in light of its
mechanism of action, i.e. production of dystrophin, ataluren should provide protection from further
damage and hence be more efficacious in less damaged muscle cells. While this would imply that
treatment should start earlier than in the decline phase, which was also supported by the SAG
Neurology experts, the CHMP maintained that the potential effect in earlier stages of the disease
was not evidenced. Overall, the CHMP considered that the patients in the decline phase of their
ambulation constituted only a subset of the study 007 population and the analysis should be seen
as exploratory. Therefore, the results to be generated in the ongoing confirmatory trial enriched
with a population of patients in the decline phase were seen as critical to addressing this issue.
The CHMP considered that even if the lack of statistical significance was disregarded, there is an
outstanding issue pertaining to the absence of effect seen in the higher dose. The applicant argued
that the finding is explained by the bell-shaped curve dose response, supporting their position by a
combination of non-clinical and clinical data. In order to further address this issue, the applicant
submitted a correlation between the plasma concentration achieved and the effect in terms of
6MWT and TFTs supporting the robustness of the effect of the selected dose (fig. 15 above). While
patients with lower concentrations appeared to show better results on 6MWD as well as across
TFTs, the CHMP considered that a scatter plot with change in 6MWT and plasma concentration on
an individual patient level would have been of greater value. This data were additionally presented
by the applicant (fig. 16 above). However, the CHMP was of the view that no specific pattern could
be identified to provide additional evidence in support of the bell shape concentration response
curve.
The data in support of the bell-shape curve hypothesis were considered to be inconsistent and not
allowing a reliable assessment. The CHMP also took into consideration the SAG Neurology comment
that additional non-clinical in vivo data would have been useful. The evidence was mainly limited to
in vitro data from myotubes derived from DMD patients and similar findings were not demonstrated
to occur in vivo. The mechanistic explanation provided by the Applicant was not considered as
sufficient level of evidence. Overall, the CHMP concluded that the effect observed in the lower dose
only could be a chance finding.
Additional expert consultation
In the course of the procedure, the CHMP identified need for input from the SAG Neurology on the
three following questions:
Question 1
Does the SAG consider that the evidence for the mechanism of action of ataluren
(nonsense mutation read-through) is convincing, and the results on dystrophin
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Question 2
Does the SAG agree that the presented pre-clinical and clinical evidence supports the
bell shaped dose-response curve and hence, the absence of efficacy at the higher dose
studied?
The SAG considered that the proposed hypothesis for the bell shaped dose response curve
seemed likely, but once again the experts felt that additional information was needed. More
specifically, it was noted that while evidence on the bell-shape dose-response curve was available
in several pre-clinical models, no data were generated in the mdx mouse model, relating the
production of dystrophin to the levels of ataluren in the muscle fibres. Such evidence would be
considered of relevance, as the available data describe only the relationship between plasmatic
levels of ataluren and dystrophin production.
Overall, the SAG was of the view that no clear-cut conclusions could be derived on the bellshaped dose-response hypothesis and the absence of efficacy in the higher dose studied in the Ph
II trial.
Question 3
Does the SAG consider, based on the data presented by the Applicant, that the observed
effects are sufficiently robust and clinically meaningful taking into account the results
on the primary and secondary endpoints? This should be discussed within the context
of starting treatment at all stages of the disease (as now claimed by the MAH) or in the
subgroup of patients with more advanced disease (where effects appear to be
different).
The SAG considered that although the results were not sufficiently robust, the demonstrated
effects were encouraging. The robustness of the results was challenged because of the observed
variability in the primary efficacy data, the fact that many of the important conclusions supporting
the efficacy of the drug were derived from the performed post hoc analyses, and the fact that
there was little supportive evidence of effect from the data on the secondary endpoints. At the
same time it was recognized that at the time the study was designed the knowledge of the
natural history of the disease was different from what we now know. It was agreed that the
applicant has performed the post hoc analyses in line with the most current knowledge about the
natural history of the disease, and in this respect the definition of the sub-groups in these
analyses is clinically and scientifically justified. The SAG experts considered that the results
derived from these may be considered clinically relevant, especially in the sub-group of patients
with more advanced disease. Additionally it was considered that the lack of effect on the
secondary endpoints could be explained by the expected mechanism of action of the drug i.e.
partial restoration of dystrophin production. Most of the secondary endpoints are of such nature
that any effect will have to be driven by an increase in strength, rather than an improvement of
function. The experts were presented with the latest available data, showing that minimal
increase in dystrophin production could lead to functional improvement, but not to improvement
of strength, and for the latter to occur, levels of dystrophin close to the ones in normal muscular
fibres must be achieved. The SAG experts agreed that this could be a valid explanation of the lack
of concordance between the primary and secondary endpoints efficacy data. It was also the
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position of the group that despite the fact that efficacy was most prominently shown in the subgroup of patients with more advanced disease, there were trends of efficacy in all the sub-groups
by severity, although of a different magnitude. This effect is to be expected, as according to the
data presented by the experts, the decline in function of Duchenne patients is not linear, but
rather the speed of functional decline increases with the duration of the disease. In that respect,
it would be very difficult to show a significant functional improvement in milder patients in the
frame of a controlled clinical trial with duration of 1 or 2 years. On the contrary, in the most
severe patients even a small effect on function would be detectable and clinically meaningful. The
patients and representatives in the room, in their statements, defended the position that at that
late stage of the disease even small effects providing longer independent use of arms and hands,
or preserving the ability to feed and drink from a cup on their own, would represent a significant
and important effect. Taking all of the above in consideration, the SAG experts felt that there
should be no scientific reason for the drug not to be given to milder patients if efficacy is
established in more severe ones. The long term benefit on this population could be documented
by a follow-up of data collected in specific registries.
Overall, considering the totality of the evidence available to date, the SAG was of the view that
while ataluren can be considered as a potentially efficacious drug, the data from the confirmatory
phase III trial are necessary before final conclusions on efficacy can be made.
This conclusion was shared by the CHMP.
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In the completed studies in patients with nmDMD, ataluren was administered three times a day at
one of three dose levels: 4, 4, 8 mg/kg; 10, 10, 20 mg/kg and 20, 20, 40 mg/kg. In the
completed studies in patients with nmCF, patients received ataluren three times a day at one of
two dose levels: 4, 4, 8 mg/kg and 10, 10, 20 mg/kg. Healthy volunteers received single doses of
ataluren up to 200 mg/kg and repeated doses up to 50 mg/kg BID for 7 days or 14 days.
Adverse events
The adverse-event profile of ataluren was comparable to that of placebo in patients with nmDMD
in the main study 007. The adverse events that were reported in 5% of patients in any
treatment arm are summarized in Table 15. The AEs which occurred twice as frequently in the
ataluren groups as compared to placebo are highlighted. None of the patients discontinued
treatment with ataluren or withdrew from the study because of a treatment-related adverse
event.
Table 15 Treatment-emergent AEs with a patient frequence of 5% by SOC (study 007)
Treatment Arm
Placebo
Ataluren
10, 10, 20
mg/kg
Ataluren
20, 20, 40
mg/kg
N=57
N=57
N=60
n (%)
n (%)
n (%)
37 (64.9)
42 (73.7)
44 (73.3)
Vomiting
22 (38.6)
32 (56.1)
27 (45.0)
Diarrhoea
14 (24.6)
11 (19.3)
17 (28.3)
9 (15.8)
9 (15.8)
13 (21.7)
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Treatment Arm
Placebo
Ataluren
10, 10, 20
mg/kg
Ataluren
20, 20, 40
mg/kg
N=57
N=57
N=60
n (%)
n (%)
n (%)
7 (12.3)
8 (14.0)
10 (16.7)
Abdominal pain
4 (7.0)
7 (12.3)
10 (16.7)
Flatulence
4 (7.0)
5 (8.8)
7 (11.7)
Stomach discomfort
4 (7.0)
5 (8.3)
General disorders
21 (36.8)
23 (40.4)
20 (33.3)
Pyrexia
12 (21.1)
14 (24.6)
7 (11.7)
6 (10.5)
4 (7.0)
5 (8.3)
2 (3.5)
3 (5.3)
4 (6.7)
43 (75.4)
38 (66.7)
39 (65.0)
Nasopharyngitis
13 (22.8)
13 (22.8)
10 (16.7)
10 (17.5)
9 (15.8)
11 (18.3)
Disease progression
Asthenia
Influenza
8 (14.0)
6 (10.5)
7 (11.7)
Gastroenteritis
4 (7.0)
9 (15.8)
3 (5.0)
Rhinitis
2 (3.5)
6 (10.5)
3 (5.0)
Ear infection
3 (5.3)
3 (5.3)
4 (6.7)
Gastroenteritis viral
3 (5.3)
4 (7.0)
3 (5.0)
26 (45.6)
28 (49.1)
31 (51.7)
Fall
7 (12.3)
11 (19.3)
6 (10.0)
Procedural pain
7 (12.3)
6 (10.5)
8 (13.3)
Contusion
3 (5.3)
6 (10.5)
4 (6.7)
Joint sprain
1 (1.8)
4 (7.0)
4 (6.7)
Investigations
4 (7.0)
10 (17.5)
6 (10.0)
Weight decreased
1 (1.8)
5 (8.8)
3 (5.0)
3 (5.3)
7 (12.3)
6 (10.0)
Decreased appetite
2 (3.5)
5 (8.8)
5 (8.3)
19 (33.3)
25 (43.9)
28 (46.7)
6 (10.5)
7 (12.3)
8 (13.3)
Back pain
5 (8.8)
9 (15.8)
6 (10.0)
Arthralgia
2 (3.5)
2 (3.5)
6 (10.0)
Muscle spasms
5 (8.8)
3 (5.3)
1 (1.7)
Muscular weakness
1 (1.8)
3 (5.3)
5 (8.3)
17 (29.8)
25 (43.9)
18 (30.0)
Headache
14 (24.6)
22 (38.6)
15 (25.0)
Dizziness
4 (7.0)
3 (5.3)
3 (5.0)
18 (31.6)
20 (35.1)
22 (36.7)
Cough
11 (19.3)
9 (15.8)
13 (21.7)
4 (7.0)
5 (8.8)
6 (10.0)
Nasal congestion
Oropharyngeal pain
Rhinorrhoea
Skin and subcutaneous tissue
disorders
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EMA/369266/2014
4 (7.0)
6 (10.5)
4 (6.7)
6 (10.5)
4 (7.0)
18 (31.6)
19 (33.3)
14 (23.3)
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Treatment Arm
Placebo
Ataluren
10, 10, 20
mg/kg
Ataluren
20, 20, 40
mg/kg
N=57
N=57
N=60
n (%)
n (%)
n (%)
Rash
5 (8.8)
4 (7.0)
8 (13.3)
Scar
3 (5.3)
4 (7.0)
5 (8.3)
The combined safety dataset for nmDMD was based on studies 007, 007e, 004e, 016 and 019.
Patients in this dataset ranged in age from 5 to 22 years and the median age was 9 years. The
combined long-term ataluren exposure was achieved in 179 nmDMD patients who received
ataluren for 48 weeks. Ataluren was generally well tolerated and the most common adverse
events (those reported in 20% of patients) included headache (40.7%), diarrhoea (27.3%),
nasopharyngitis (26.4%), cough (25.0%), upper abdominal pain (21.8%), pyrexia (21.8%), fall
(20.8%) and upper respiratory tract infection (20.8%).
Serious adverse event/deaths/other significant events
Deaths
There were no deaths during the completed clinical studies of ataluren in nmDMD patients. In the
ongoing open-label safety study for previously treated ataluren patients with nmDMD, study 016
(PTC124-GD-016-DMD), three cases of death were reported: a 22-year old male patient treated
with ataluren for ~9 months, a 21-year old male patient treated with ataluren for ~14 months
and 10-year old male patient treated with ataluren for ~18 months. Causal relationship between
the fatal outcomes and treatment with atualuren was not found.
Serious AEs
In study 007, serious adverse events were reported in 5.3% (3 of 57) subjects in the placebo
arm, in 3.5% (2 of 57) patients in the ataluren 10, 10, 20 mg/kg arm and in 3.3% (2 of 60)
patients in the ataluren 20, 20, 40 mg/kg arm.
ataluren arm was considered by the investigator to be related to ataluren (Table 16).
Table 16: Serious Adverse Events in nmDMD Placebo-controlled study 007
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There were 21 SAEs reported from studies 007,007e, 004 and 004e. Fourteen of these SAEs were
reported in patients receiving ataluren and only one (hypertension) was considered by the
applicant as likely related to the ataluren. The case of paroxysmal supraventricular tachycardia
was considered unlikely related to study drug by the applicant, because the patient had previously
experienced similar symptoms and self-limiting episodes.
There were three SAE cases of hypertension (1 in 007e and 2 in 004e) of which one was
considered as related to ataluren. In addition there were five cases of bone fractures reported
(four fractures of femur and one of lower limb) of which one occurred in the placebo arm and 4 in
patients treated with ataluren; none of these cases was considered by the investigators to be
related to ataluren.
Laboratory findings
Data obtained in healthy volunteers indicated that exposure to ataluren could cause elevation of
liver enzymes (but not bilirubin), serum cholesterol and triglycerides. These changes seemed to
be dose-dependent and reversible after exposure to ataluren was stopped.
No significant haematology findings or signals of renal toxicity and effects on adrenal function
were seen in studies 007 and 007e. The only finding was hepatic toxicity, which was expected
given the data from healthy volunteers. There were ten ataluren-treated patients and one
placebo-treated patient with isolated Grade 1 (mild) elevations in GGT or total bilirubin. Mean
cholesterol and triglycerides levels were in the upper range of normal at baseline and increased to
borderline-high or high levels in the ataluren arms and, to a lesser extent, in the placebo
treatment arm during treatment, primarily in patients who were receiving corticosteroids (Table
17).
Table 17 Mean Change in Cholesterol and Triglycerides by Treatment Arm and Corticosteroid use
in nmDMD Placebo-Controlled Study 007.
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No clear relationship was identified between pulse rate, respiration rate or temperature and the
use of ataluren, but increased blood pressure was observed (table 18). This increase was slightly
higher in the subgroup using corticosteroids than in the subgroup not using corticosteroids. There
was also a slight increase in the diastolic blood pressure in all treatment arms.
Table
18:
Mean
Change
in
Blood
Pressure
in
nmDMD
Placebo-Controlled
Study
007.
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were characterised by elevated creatinine (Grade 1 to Grade 4), which resolved over days to
weeks.
All
seven
events
were
associated
with
concomitant
systemic
treatment
with
aminoglycosides or other potentially nephrotoxic antibiotics (e.g. vancomycin) that were generally
administered as treatment for pulmonary exacerbations. No patient required dialysis. This issue
was recognized during the conduct of this study and changes were made in the protocol
(prohibition of concomitant use of intravenous aminoglycosides or other potentially nephrotoxic
antibiotics), which successfully addressed the issue.
Discontinuation due to adverse events
A total of 6 of the 216 nmDMD patients (2.8%) discontinued treatment because of one or more
adverse events. Vomiting was reported as the reason for discontinuation of treatment in two
patients. One patient discontinued due to a Grade 1 micturition disorder, indicated as unlikely
related to study drug. After the interim database cut-off date for Study 016, one additional
patient discontinued due to abnormal cystatin C and BUN values.
Discontinuation due to adverse events was also seen in the nmCF studies (e.g. due to renal and
urinary disorders).
information on safety was derived from studies in other conditions (nmCF, nmHA/HB and
nmMMA).
With respect to data from the phase 1 studies, next to headache and gastrointestinal adverse
events, there were signals that exposure to ataluren could lead to elevation of liver enzymes as
well as serum cholesterol and triglycerides. Cases of hepatic toxicity (elevated liver enzymes)
were seen also in DMD patients in the pivotal phase 2 study 007. While these changes seemed to
be reversible after exposure to ataluren was stopped, the CHMP considered that ataluren was
intended for continuous life-long use and hence, reversibility of elevated liver enzymes was seen
as less relevant for the target population. Overall, the CHMP considered hepatotoxicity as an
important potential risk.
Similarly, the effect of ataluren on cholesterol and triglyceride levels was also documented in DMD
patients. In study 007, mean cholesterol and triglyceride levels increased to borderline-high or
high levels in both ataluren treatment arms and to a lesser extent in the placebo arm and the
increase was more prominent in patients who received corticosteroid therapy. The CHMP
considered that this would be the case in the majority of DMD patients in clinical practice and
considered this finding as a safety concern.
The treatment-related adverse events reported most commonly in the study 007 (i.e. in 5% of
patients across all 3 treatment arms) were vomiting, diarrhoea, upper abdominal pain, flatulence,
nausea, headache and decreased appetite. The CHMP considered that most of these occurred with
similar frequency in the placebo and ataluren arms. The adverse events vomiting, flatulence,
stomach discomfort and fatigue were seen to increase in frequency from placebo to ataluren 10,
10, 20 mg/kg to ataluren 20, 20, 40 mg/kg.
Increase in systolic and to a less extent in diastolic blood pressure was observed in subjects
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treated with ataluren and there were three cases of hypertension, some of which required
antihypertensive treatment. The CHMP considered that the use of corticosteroids may have
contributed to these cases. However, if authorised, ataluren would be used mostly in combination
with corticosteroids and thus, the potential risk of hypertension with concomitant use of
corticosteroids was considered as a safety concern by the CHMP, particularly in the context of a
disease with frequent development of cardiomyopathy.
Based on the combined safety dataset analysis, i.e. data from patients in studies 007, 007e,
004e, 016 and 019, the CHMP considered that ataluren was generally well tolerated by patients
with nmDMD, with the most common adverse events (those reported in 20% of patients) being
those that are typical of paediatric illnesses or DMD complications, e.g. headache (41%),
diarrhoea (27%), nasopharyngitis (26%), cough (25%), upper abdominal pain (22%), pyrexia
(22%), fall (21%) and upper respiratory tract infection (21%).
Additionally, the safety analysis indicated the changes in the lipid profile, hypertension, renal and
hepatic events need to be considered as safety concerns and reflected in the Risk Management
Plan.
The CHMP considered there were only few treatment-related serious adverse events. Femur
fracture (4.2%) was the most frequently reported serious adverse event, but none of these
fractures which met the criteria for a serious adverse event was considered by the investigators to
be related to ataluren. Although the causal relationship was not suggested by the investigators,
the CHMP paid attention to this signal, considering that lower limb fractures in DMD patients may
lead to immobilization which may become permanent, i.e. transition to non-ambulation. Further
to their review of additional data on lower limb and on all fractures both in nmDMD and in nmCF
patients, the CHMP concluded that over comparable periods, there was no signal of higher
frequency of fractures in subjects exposed to ataluren, as compared to placebo.
With respect to specific patient populations, the CHMP considered that no studies were conducted
in patients with renal or hepatic impairment and safety in these populations was not fully
established. Since renal excretion accounts for ~ 50% of the drug elimination, renal impairment is
likely to result in accumulation of ataluren and/or ataluren glucuronide. Similarly, since ataluren is
extensively metabolized in liver, hepatic impairment is expected to result in ataluren increased
plasma concentrations. Taken together with the uncertainties around the claimed bell-shaped
dose-response curve, the CHMP considered that without clinical data, understanding of both
efficacy and safety profile of ataluren in subjects with renal or hepatic impairment remains
limited.
The CHMP considered that no immunological events were reported in the DMD patients treated
with ataluren. Although immunological reactions are not expected for this type of compound, the
Applicant was requested to review all available data, including those from the CF clinical
programme. Two CF patients receiving ataluren had allergic reactions possibly related to the
investigational drug, as compared to one patient on placebo. Based on the data available,
atalurens potential for immunogenicity was considered low by the CHMP.
Despite substantial differences between the DMD and CF patient populations (differences in
demographics, concomitant medications, complications of the disease, overall health status/ need
for hospitalisations), the safety data from the combined nmCF population was considered
supportive of the safety profile for ataluren in nmDMD. Ataluren was generally well tolerated by
the nmCF patients, who were exposed to ataluren in the two long-term studies for up to two
years. The adverse events were typical of CF and included cystic fibrosis pulmonary exacerbation
(84%), cough (32%), viral upper respiratory tract infection (28%) and pyrexia (22%) as the most
frequently reported treatment-emergent adverse events (reported in 20% of patients). Most of
the adverse events were Grade 1 or Grade 2 in severity, were not attributed to ataluren and did
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not lead to discontinuation of treatment with ataluren. The data generated in the CF patients also
provided evidence of interactions between ataluren and i.v. aminoglycosides, which was
considered of relevance and supportive of a respective contraindication should the product be
authorised. Ultrasound examinations (in nmDMD and nmCF studies) identified cases of abnormal
renal ultrasound findings. In particular, the nmCF study data suggested a clear effect of ataluren
on renal abnormalities. Of note, five events of renal disorders were reported as serious adverse
events in nmCF patients. The CHMP considered that although the mechanism of a potential
contribution of ataluren to the reported cases of nephrotoxicity was not known, this signal in the
clinical development appeared to reinforce the non-clinical findings seen in mice. Based on the
clinical data available, renal toxicity was assumed to occur less likely in DMD patients, but was
still perceived as a safety concern. The CHMP concluded that it should be considered as a
potential important risk.
The CHMP pointed out a theoretical concern about possible effects of ataluren on reading through
normal stop codons and hence producing abnormally elongated proteins. This was investigated in
healthy volunteers and the results did not confirm that this would be the case. This was
considered re-assuring by the CHMP. However, these analyses were performed on a number of
selected proteins and on pooled samples from peripheral blood of healthy volunteers. Moreover,
the CHMP noted that the non-specific read through of normal stop codons should be examined in
a range of plasmatic concentrations which are expected to bring about the read-through in DMD
patients. In response to this concern, lysates from muscle biopsies obtained from 48 nmDMD
patients treated with ataluren 10, 10, 20 mg/kg for 36 weeks (Study 007) were analysed by
Western blotting. Two muscle proteins were examined (GAPDH and -actin) without further
evidence of protein elongation. Nevertheless, the CHMP was of the view that the theoretical risk
of non-specific read-through of normal stop codons still remains an uncertainty.
Furthermore, the CHMP flagged a theoretical concern that ataluren could enhance read through of
non-sense mutations in other genes. The applicant discussed the potential endogenous nonsense
codons substrates for ataluren presenting theoretical arguments why no effect on these would be
expected. However, no data were submitted in support of these statements. Overall, the CHMP
concluded that the potential off-target effects were an uncertainty about the risks related to the
mechanism of action of ataluren.
2.7. Pharmacovigilance
Detailed description of the pharmacovigilance system
The CHMP considered that the Pharmacovigilance system as described by the applicant fulfils the
legislative requirements.
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PRAC Advice
Based on the PRAC review of the applicants response to the previous list of questions referring
to the Risk Management Plan version 1.2, the PRAC considered by consensus that the risk
management plan for Translarna (ataluren) in the proposed treatment of Duchenne muscular
dystrophy, resulting from a nonsense mutation in the dystrophin gene (nmDMD) in ambulatory
patients aged 5 years and older, could be acceptable provided that an updated risk management
plan is submitted before final CHMP opinion, addressing the following issues:
The summary table of risk minimisation measures should be edited, as no additional risk
minimisation measures are planned for any of the safety concerns in the RMP. In the absence of
educational materials, the relevant sections of the RMP should be edited to clarify how health-care
professionals (and patients if needed) will be advised about the need for monitoring of the patients
lipid profile, renal and hepatic function monitoring and for the monitoring of blood pressure.
Genetic testing might also be considered. Furthermore, the reported risk minimisation measures in
the summary table should be limited to SmPC (i.e. no Package Leaflet references are expected).
Please note that amendments are needed in the proposed SmPC to ensure monitoring
Part VI of the RMP (Summary of activities in the risk management plan by product) table
This advice is based on the following content of the Risk Management Plan:
Safety concerns
corticosteroids
Missing information
Renal toxicity
Hibernoma
Malignancies in general
impairment
impairment
years
Caucasian
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Pharmacovigilance plans
Activity/Study title
Objectives
(type of activity,
Safety concerns
Status Planned,
addressed
started,
Changes in lipid
profile
Planned
Category 1
Hypertension with
use of concomitant
systemic
corticosteroids
Renal toxicity
Effect of coadministration of
ataluren with
nephrotoxic drugs
other than
intravenous
aminoglycosides
Use in patients with
moderate to severe
hepatic impairment
Use in patients with
moderate to severe
renal impairment
Potential use in
children from 6
months to 5 years
Use in patients
whose ethnic origin
is other than
Caucasian
Extended long-term
safety
Off-label use in
patients who do not
have DMD caused
by a nonsense
mutation in the
dystrophin gene
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug
interaction studies
Potential use in
children from 6
months to 5 years
Planned
Category 3
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Activity/Study title
Objectives
(type of activity,
Safety concerns
Status Planned,
addressed
started,
Potential use in
children from 6
months to 5 years
Planned
Potential use in
children from 6
months to 5 years
Planned
Further investigation
of atalurens
potential effect in
the development of
hibernomas
Planned
Further investigation
of atalurens
potential effect in
the development of
hibernomas
Planned
Potential use in
children from 6
months to 5 years
Planned
Planned
Planned
Effect of
coadministration of
ataluren with certain
drugs not yet
Planned
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Activity/Study title
Objectives
(type of activity,
Safety concerns
Status Planned,
addressed
started,
evaluated in formal
drug-drug
interaction studies
Effect of
coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug
interaction studies
Effect of
coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug
interaction studies
Effect of
coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug
interaction studies
Planned
Effect of
coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug
interaction studies
Planned
Effect of
coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug
interaction studies
Planned
Planned
Planned
Safety concern
Additional risk
minimisation
measures
Potentiation of aminoglycoside
renal toxicity
None proposed
Page 64/101
Safety concern
Additional risk
minimisation
measures
Aminoglycosides
Translarna should not be co-administered
with intravenous aminoglycosides, based on
cases of decreased renal function observed in
a clinical trial in patients with nonsense
mutation cystic fibrosis (nmCF) (see section
4.3).
Elevations of serum creatinine occurred in
several nmCF patients treated with Translarna
and intravenous aminoglycosides together
with other antibiotics for cystic fibrosis
exacerbations. The serum creatinine
elevations resolved in all cases, with
discontinuation of the intravenous
aminoglycoside, and either continuation or
interruption of the study drug. These findings
suggested that co-administration of
Translarna and intravenous aminoglycosides
may potentiate the nephrotoxic effect of the
aminoglycosides. Treatment with Translarna
can be resumed 2 days after administration of
the aminoglycoside has ended. The effect of
co-administration of ataluren with other
nephrotoxic drugs is unknown.
Dehydration may be a contributing factor in
some of these cases. Patients should maintain
adequate hydration while taking Translarna.
PIL section 2
(What you need to know before you take
Translarna)
Do not take Translarna if you are taking
injection by vein for antibiotics, such as
gentamicin, tobramycin, or streptomycin.
(Other medicines and Translarna)
Tell your doctor if you are taking, have
recently taken, or might take any other
medicines. In particular do not take
Translarna with gentamicin, tobramycin, or
streptomycin injections.
These may affect your kidney function.
Changes in lipid profile
Monitoring of the
on an annual basis.
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Safety concern
Additional risk
minimisation
measures
Monitoring of resting
of corticosteroids
Renal toxicity
Monitoring of the
(serum creatinine,
Table 1.
BUN, cystatin C)
every 6 to 12 months.
None proposed
None proposed
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Safety concern
Additional risk
minimisation
measures
of this medicine.
Use of ataluren in nmDMD patients
nephrotoxic drugs
interaction)
None proposed
of administration)
impairment
None proposed
of administration)
impairment
None proposed
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Safety concern
Additional risk
minimisation
measures
indications)
None proposed
properties)
Caucasian
None proposed
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None proposed
None proposed
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Safety concern
Additional risk
minimisation
measures
Safety
Off-label use of ataluren in patients
Central certification of
nonsense mutation in
genetic testing.
required for
prescription to be
filled.
interaction studies
None proposed
The CHMP, having considered the data submitted in the application was of the opinion that it was
not appropriate to consider pharmacovigilance activities and risk minimisation measures at this
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time.
3. Benefit-Risk Balance
Benefits
Beneficial effects
Ataluren is a first-in-class drug designed to enable ribosomal readthrough of premature stop
codons, resulting in the formation of a full-length functional protein in patients with nonsense
mutation genetic disorders. In the proof of concept study in mdx mice ataluren was seen to
promote formation and adequate localization of dystrophin, resulting in increased muscle strength
and prevention of loss of strength following repeated contractions.
In the clinical setting, beneficial effects of the lower dose (10, 10, 20 mg/kg) were claimed in
both primary and secondary endpoints of physical functioning.
With respect to 6MWD, ataluren was observed to slow disease progression in nmDMD patients.
The post-hoc analysis in the cITT population indicated an estimated difference in the Change in
6MWD at Week 48 of 31.7 metres (nominal p=0.0281, adjusted p=0.0561, observed mean
difference in 6MWD=31.3 metres) between the 10, 10, 20 mg/kg dose and placebo. Looking at
the proportions of patients with at least 10% worsening in 6MWD at Week 48, 44% vs 26% of
patients in the placebo and the 10, 10, 20 mg/kg ataluren arm, respectively were progressors
(nominal p=0.0326, adjusted p=0.0652) .
A greater effect over 48 weeks was seen in patients in the ambulatory decline phase, i.e.
patients between 7 and 16 years of age, with baseline 6MWD 150m and 80% of predicted
value. Based on a post-hoc subgroup analysis in this population, a difference in the change in
6MWD at Week 48 of 49.9 metres (p=0.0096) between the 10, 10, 20 mg/kg dose and placebo
was seen.
In terms of secondary endpoints of physical functioning, only limited effects of ataluren were
observed: ataluren patients had fewer falls/week than placebo-dosed patients; increase of
wheelchair use from baseline was less in ataluren than placebo; ataluren patients spent less time
in no activity (based on Step activity monitoring) and a minor positive trend was observed in
myometry tests.
Uncertainty in the knowledge about the beneficial effects
The CHMP was of the view that the main uncertainties about the claimed beneficial effects
pertained to the robustness of efficacy data in general, the dose-response curve (and hence the
appropriate dose) and the applicability of the data to the overall target population.
Uncertainties about robustness of efficacy data
The primary analysis of the pivotal study 007 indicated an estimated difference of 26.4 m
between placebo and the low dose arm; this, however, was not statistically significant (nominal
p=value 0.0905, adjusted p value=0.1592) and by the usual statistical standards, the study was
formally negative. In order to explain the findings in study 007, the Applicant performed a
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number of post hoc analyses. These consistently showed a similar difference in 6MWD, but the
wide confidence intervals reflected the uncertainty in the estimate.
The CHMP was of the view that the results on the secondary endpoints provided only limited
support for the primary endpoint outcomes, as they were inconsistent, difficult to interpret and
needed to be seen only as trends. Nevertheless, in line with the input from the SAG Neurology,
the CHMP acknowledged that most of the secondary endpoints were of such nature that any effect
would have to be driven by an increase in strength and for this to occur, higher levels of
dystrophin in muscular fibres would have to be achieved.
Pharmacodynamic confirmation of efficacy was not provided by the pivotal study, despite the fact
that biopsies were collected. While the technical problems with dystrophin quantification were
recognised by the CHMP, the quality of the biopsies supplied was of concern. The GCP inspection
identified that several steps were underestimated, namely instructions for performing the muscle
biopsies and the storage/ shipping logistics. Since the mechanism of action of ataluren is claimed
to be by promoting production of a full-length dystrophin, more prominent evidence of dystrophin
in muscle of patients treated for 48 weeks would be expected. Considering the limitations of data
on clinical efficacy, the CHMP pointed out that the dossier would have benefited from supportive
data on pharmacodynamics and their absence was seen as adding to the uncertainties.
Uncertainties about the dose-response curve and dose
The CHMP considered that one of the critical issues was the absence of effect in patients treated
with the higher dose. The applicant argued that the finding could be explained by the bell-shaped
curve dose response, supporting their position by a combination of in vitro data (e.g. human
myotube cultures, nmDMD mouse myotubes and nmDMD zebrafish) and clinical data (studies
004e, 007 and 007e). The bell-shape response curve was however not obvious based on the in
vivo preclinical data and the phase 2a clinical data, i.e. before the design and start of the clinical
studies 004e, 007 and 007e.
In order to further address this issue, the applicant submitted a correlation between the plasma
concentration achieved and the effect in terms of 6MWT and TFTs supporting the robustness of the
effect of the selected dose. While patients with lower concentrations appeared to show better
results on 6MWD as well as across timed function tests, the CHMP considered that a scatter plot
with change in 6MWT and plasma concentration on an individual patient level would have been of
greater value. This data were additionally presented by the applicant, but no specific pattern could
be identified to provide additional evidence in support of the bell shape concentration response
curve.
Overall, the data in support of the bell-shape curve hypothesis were considered to be inconsistent
and not allowing a reliable assessment. The CHMP concluded that the effect observed in the lower
dose only could be a chance finding.
Validity of data for the entire nmDMD patient population
Since efficacy was investigated in a subgroup of ambulant DMD boys and documented mainly on
ambulation parameters, extrapolation to the broader nmDMD patient population (including nonambulant subjects) was not supported by sufficient evidence.
Risks
Unfavourable effects
Ataluren was generally well tolerated by patients with nmDMD, with the most common adverse
events being headache and gastrointestinal disorders such as nausea, vomiting, (upper)
abdominal pain, flatulence, diarrhoea, stomach discomfort, constipation and regurgitation.
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The laboratory data indicated that exposure to ataluren could cause elevation of serum
cholesterol and triglycerides. Mean cholesterol and triglycerides levels were in the upper range of
normal at baseline and increased to borderline-high or high levels in the ataluren arms, primarily
in patients who were receiving corticosteroids. The values tended to stabilize early and did not
increase further with continued treatment. Changes in the lipid profile were considered as an
important identified risk in the proposed Risk Management Plan.
Of note, elevations of serum creatinine occurred in several patients with nonsense mutation cystic
fibrosis treated concomitantly with intravenous aminoglycosides. In all cases, the elevations
resolved with discontinuation of the aminoglycosides indicating that co-administration of ataluren
and intravenous aminoglycosides may potentiate the nephrotoxic effect of the aminoglycosides.
Based on this evidence of decreased renal function, potentiation of aminoglycoside renal toxicity
was determined as an important identified risk.
There were no deaths during the placebo controlled study. Three fatal cases were seen in one
open-label study, but the fatal outcomes were not considered related to treatment with ataluren.
Uncertainty in the knowledge about the unfavourable effects
From the non-clinical database, the finding of malignant hibernomas in rat raised the concern as
to whether occurrence of similar effects could be expected in humans, particularly in the
paediatric population where the quantity of the brown adipose tissue is higher. In particular, the
CHMP considered that malignant hibernomas could be related to the effects of ataluren on fat
tissue metabolism and to effects on plasma lipid parameters, which were observed in rats, dogs
and humans. Thus, hibernomas were reflected in the proposed risk management plan of
ataluren as an important potential risk.
Considering the mechanism of action of ataluren, the CHMP pointed out a theoretical concern
about possible effects of ataluren on reading through normal stop codons (and thus producing
abnormally elongated proteins) and a concern that ataluren could enhance read through of nonsense mutations in other genes. Although such effects were not seen in the data available, the
CHMP was of the view that the potential off-target effects were an uncertainty about the risks of
ataluren.
Based on results of in vitro studies, ataluren was expected to have an interaction potential, which
the CHMP considered necessary to be explored further in vivo. This pertained to ataluren
interactions with a BCRP inhibitor, UGT1A9 substrate, OAT1, OAT3 and OATP1B3 substrates and
UGT1A9 selective inducer.
Increase in blood pressure including cases of hypertension requiring antihypertensive treatment
was observed in subjects treated with ataluren. While this could have been due to the use of
corticosteroids administered concomitantly, this issue was considered an uncertainty and captured
as a potential risk in the proposed Risk Management Plan.
The preclinical data as well as data from healthy volunteers and DMD patients indicated that
exposure to ataluren may lead to increase in transaminases. While these changes seemed to be
reversible after exposure to ataluren was stopped and a clear hepatotoxic effect was not
confirmed, the CHMP considered hepatotoxicity as an important potential risk.
The nmCF study data suggested an effect of ataluren on renal abnormalities. Although the
mechanism of a potential contribution of ataluren to the reported cases of nephrotoxicity was not
known, this signal in the clinical development appeared to reinforce the non-clinical findings seen
in mice. Based on the clinical data available, renal toxicity was assumed to occur less likely in
DMD patients, but was still perceived as a potential important risk.
Treatment of patients with renal or hepatic impairment is another area of uncertainty, as no
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specific
studies
were
performed
and
potential
safety
concerns
are
implied
by
the
pharmacokinetics of ataluren. Since renal excretion accounts for ~ 50% of the drug elimination,
renal impairment is likely to result in accumulation of ataluren and/or ataluren glucuronide.
Similarly, since ataluren is extensively metabolized in liver, hepatic impairment is expected to
result in ataluren increased plasma concentrations. Taken together with the uncertainties around
the claimed bell-shaped dose-response curve, the CHMP considered that without clinical data,
understanding of both efficacy and safety profile of ataluren in subjects with renal or hepatic
impairment remains limited.
Benefit-risk balance
Importance of favourable and unfavourable effects
Several lines of evidence support the clinical relevance of a 30-meter difference in 6MWT,
including a report2 showing that a 30-meter change in 6MWD over 48 weeks can be considered a
clinically meaningful change based on the patient/parent-reported quality of life measures in DMD
patients. This is also supported by results of longitudinal LMWT natural history data in DMD,
indicating that each 30-meter decrease in baseline 6MWD predicts increasing risk of loss of
ambulation over the following 2 years.
Ability to climb and descend a short grouping of stairs, abililty to run in short bursts, or to walk a
short distance unaided, e.g. to a bathroom, reflect the typical activities important in the lives of
DMD patients. Importantly, recent data indicated that timed function tests evaluating these
abilities are, similarly to 6MWT, predictive of the time for a patient to become non-ambulatory.
Natural history data from the Cooperative International Neuromuscular Group indicated that
changes in these parameters are predictive of the likelihood of loss of ambulation over 1 year.
Falls commonly lead to fractures in DMD patients and the injuries sustained may accelerate loss
of ambulation. Decreasing the rate of accidental falls and hence the risk of fractures, pain and
other trauma would be of benefit to the patients. With respect to decrease in wheel chair use,
benefits can be attributed not only in terms of ambulation itself, but also by positively impacting
on the respiratory function and minimalisation of scoliosis. Thus, if sufficiently documented these
effects would be considered of high importance.
The most commonly reported treatment-related adverse events vomiting, diarrhoea, abdominal
pain upper, flatulence, nausea, headache and decreased appetite were not considered to raise
major safety concerns in a seriously debilitating and life-threatening condition such as DMD.
The effect of ataluren on the lipid profile (cholesterol and triglyceride levels) was considered of
importance, especially in a situation where long-term administration of corticosteroids is
expected. Nevertheless, the values tended to stabilize early in the study and did not increase
further with continued treatment, which was considered re-assuring. Similarly, the risk of
hypertension during concomitant use of corticosteroids and ataluren was seen as of importance to
the target population, considering that such co-administration would occur in the majority of
patients in the clinical practice.
In the context of the age group targeted, the potential risk of hibernoma was considered relevant,
due to higher proportion of brown fat tissue in children.
Henricson E, Abresch R, Han JJ, Nicorici A, Goude Keller E, de Bie E, McDonald CM. The 6-Minute Walk Test and
Person-Reported Outcomes in Boys with Duchenne Muscular Dystrophy and Typically Developing Controls: Longitudinal
Comparisons and Clinically-Meaningful Changes Over One Year. PLOS Currents Muscular Dystrophy. 2013 Jul 8;
5:ecurrents.md.9e17658b007eb79fcd6f723089f79e06. doi:
10.1371/currents.md.9e17658b007eb79fcd6f723089f79e06
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Overall, the CHMP was of the view that the risks of the product could be considered acceptable if
there were data providing sufficient level of evidence that ataluren may be beneficial in delaying
disease progression in nmDMD. However, considering the totality of data available and the
uncertainties described above, the CHMP concluded that a favourable benefit-risk balance could not
be established at this point.
The applicant applied for a conditional marketing authorisation with the proposal that additional
data would be generated post-authorisation in the confirmatory phase 3 study PTC124-GD-020DMD (Study 020). Therefore, the CHMP also discussed the criteria that would need to be met for a
conditional approval and made the following conclusions:
DMD is a life-threatening and chronically debilitating condition where no satisfactory
methods of treatment exist and it was considered that the product would thus address an unmet
medical need.
The CHMP pointed out that while in case of an orphan condition the clinical dataset might
not be fully comprehensive, the evidence of efficacy should be sufficient to allow assessment and
concluding on a favourable benefit-risk balance. As discussed above, a favourable benefit risk
balance of ataluren was not considered established at this point.
The criterion that the benefits to public health of the immediate availability outweigh the
risks inherent in the fact that additional data are still required was not considered fulfilled since the
benefits to public health were not substantiated by the data presented in the dossier.
With respect to generating additional data post authorisation, the CHMP considered that
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4. Recommendations
Based on the CHMP review of data on quality, safety and efficacy for Translarna in the treatment
of Duchenne muscular dystrophy resulting from a nonsense mutation in the dystrophin gene, in
patients aged 5 years and older the CHMP considers by majority decision that the efficacy of the
above mentioned medicinal product is not sufficiently demonstrated and therefore recommends
the refusal of the granting of the conditional Marketing Authorisation for the above mentioned
medicinal product. The CHMP considers that:
Translarna in terms of the primary endpoint (6MWT) and further efficacy parameters confirming
functional improvement and activities of daily living. Furthermore, the mechanism of action and
the bell shape dose-response relationship of Translarna were not conclusively established, which
adds further uncertainty on the overall robustness of the efficacy data.
Therefore, the CHMP was of the opinion that pursuant to Article 12 of Regulation (EC) No
726/2004, the efficacy of the above mentioned medicinal product is not properly or sufficiently
demonstrated.
Furthermore, the CHMP considered that the Applicant has not convincingly shown that
comprehensive data can be obtained from the confirmatory placebo-controlled trial if the product is
authorised and available on the market.
Due to the aforementioned concerns a satisfactory summary of product characteristics, package
leaflet and risk management plan to address other concerns as outlined in the list of outstanding
issues cannot be agreed at this stage.
Furthermore, the CHMP, in light of the negative recommendation, is of the opinion that it is not
appropriate to conclude on the new active substance status at this time.
Divergent positions to the majority recommendation are appended to this report.
Re-examination of the CHMP opinion of 22 May 2014
Following the CHMP conclusion that Translarna was not approvable due to the lack of established
efficacy, the applicant submitted detailed grounds for the re-examination of the grounds for
refusal.
Detailed grounds for re-examination submitted by the applicant
The applicant presented their detailed grounds for re-examination in writing and at an oral
explanation.
A summary of the applicants grounds for re-examination is presented below.
The Applicant requested a re-examination of the CHMP opinion on Translarna, claiming that
substantial evidence is available for granting a conditional marketing authorisation in the following
indication:
Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a
nonsense mutation in the dystrophin gene, in ambulatory patients aged 5 years and older.
Efficacy has not been demonstrated in non-ambulatory patients.
The presence of a nonsense mutation in the dystrophin gene should be determined by genetic
testing.
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Overall, the Applicant was of the view that ataluren has a favourable benefit-risk profile in
nmDMD patients, which is a population suffering from a fatal disease with high unmet medical
need, and maintained that criteria for a conditional marketing authorisation were fulfilled.
Ground 1: The single study fails to demonstrate persuasive evidence of therapeutic efficacy of
Translarna in terms of the primary endpoint (6MWT) and further efficacy parameters confirming
functional improvement and activities of daily living. Furthermore, the mechanism of action and
the bell shape dose-response relationship of Translarna were not conclusively established, which
adds further uncertainty on the overall robustness of the efficacy data.
The applicant re-iterated that the ataluren phase 2b study (Study 007) was the first registrationdirected trial in DMD. The lack of an accepted primary endpoint in DMD prior to the conduct of
this study required that the company establish the 6MWT as the primary endpoint, as a result of
which the 6MWT is now an accepted primary outcome measure in DMD clinical trials. In Study
007, the 6MWD results met the MCID for 6MWD in DMD, demonstrating clinical meaningfulness in
a heterogeneous population (estimated 31.7 meters 6MWD benefit over placebo, in the cITT
analysis (post-hoc analysis), adjusted p=0.056). One indication of the robustness of the results
was that slowing of disease progression was also shown in the pre-specified analysis of time to
10%-worsening in 6MWD, in which only 26% of patients who received ataluren 10, 10, 20 mg/kg
experienced disease progression, compared with 44% of the patients who received placebo. The
applicant claimed that the difference between the ataluren 10, 10, 20 mg/kg treatment group and
the placebo group was apparent as early as Week 24 in this analysis.
The applicant highlighted that, given the role of dystrophin in stabilizing muscles and the natural
history of ambulation based on the 6MWT, the effect of ataluren is most evident in patients who
are in the ambulatory decline phase of the disease in a 48-week clinical trial. The eligibility criteria
for the ongoing confirmatory Phase 3 study (study 020) were designed on this basis: age 7 and
16 years; baseline 6MWD 80% of predicted for age and height, (and, to enhance uniformity,
on corticosteroids, and baseline 6MWD 150 meters). Applying these criteria to the Study 007
population, a larger ataluren effect in 6MWD was seen in this decline phase subgroup (49.9
meters, p=0.0096). These data were further supported by the results in patients with more
advanced disease, with baseline 6MWD <350 meters, which indicated a difference for the primary
outcome measure as well as trends favouring ataluren in the TFTs on the lower limb, wheelchair
usage, and the HRQL patient-reported physical function domain.
Furthermore, the robustness of the 6MWT results was in the Applicants view supported by the
positive trends seen in the key secondary endpoints, i.e. TFTs, that represent daily activities and
also predict risk of loss of ambulation. As seen in the 6MWT, the trends in TFTs on the lower limb
were larger in the subgroup enriched for the decline phase than in the overall study population.
The internal consistency of the 6MWD and TFT results was demonstrated in Monte Carlo
simulations, in which 10% of patients were randomly removed from each treatment arm, and the
analysis repeated 1000 separate times. The Monte Carlo analyses and other sensitivity analyses
(such as removal of best/worst patients and the randomization-based ANCOVA analysis)
demonstrated that the results of the study were robust.
Further evidence of the robustness of the data seen was constituted by the positive trends
observed in other secondary endpoints, which pointed in the same direction as the 6MWT and
TFTs: step activity monitoring, wheelchair use, accidental falls, and the QOL child physical
function domain. The results for wheelchair use and the QOL child physical function domain, like
the 6MWT and TFTs, showed larger effect sizes in the subgroup of patients in the ambulatory
decline phase. The totality of the data was considered compelling by the Applicant when looking
at the aggregately positive trends for ataluren vs placebo across outcome measures. With respect
to muscle strength, the applicant pointed out that its measurement is not a relevant outcome for
the evaluation of a dystrophin restoration therapy, making reference to studies using the mdx
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mouse which indicated that dystrophin levels correlate with changes in muscle function but not
with muscle strength.
In terms of dystrophin production, positive differences in dystrophin expression were seen in
ataluren-treated patients in the Phase 2a study. These data were considered by the Applicant to
support the bell-shaped dose response since the majority of patients had plasma concentrations
less than 20 g/ml.
The Applicant acknowledged that those results were not replicated in the
Study 007, giving a variety of reasons, including biopsy sample issues, technical problems, and
shipping and handling-introduced artefacts. Of note, despite considerable technical limitations in
the Phase 2b study, the largest %-increase in dystrophin and the largest number of patients who
exceeded the value of 40% increase were in the 10, 10, 20 mg/kg group, compared to the 20,
20, 40 mg/kg and placebo groups. To put the limited evidence into perspective, the Applicant
made reference to the EMA draft guideline [EMA 2013], specifically to sections recognising that
dystrophin is not a validated biomarker and may provide only complementary information during
diagnosis, and the fact that muscle biopsies are debatable regarding the robustness and the
precise quantification of extremely low levels of dystrophin.
The published in vivo demonstration of atalurens readthrough ability was considered by the
Applicant to be corroborated by the efficacy of ataluren in both the mdx mouse and zebrafish
model of nmDMD. Furthermore, the Applicant documented that atalurens readthrough activity
was thoroughly verified by a number of independent investigators in other disease models (Hurler
syndrome, cystic fibrosis).
With respect to the bell-shaped dose response, several lines of evidence were submitted by the
Applicant in its support, including observations of a bell shaped response in muscle cell cultures
from mdx mice and nmDMD patients, mouse embryonic fibroblasts (MEFs) of nmHurler mice and
in a zebrafish nmDMD model in vivo (sapje mutant).
similarities between the ribosomal binding mechanism of ataluren and aminoglycosides, which
also show a bell-shaped response, highlighting that the dose-response relationship is not caused
by adverse effects of ataluren.
concentration-based analyses of ataluren in the clinical studies was presented as consistent with
the bell-shaped dose-response hypothesis. In particular, the Applicant presented additional
analyses based on C0h (fig. 17) documenting that the same trend is observed as within the
analyses based on C2h, i.e. higher efficacy in patients with lower concentrations.
Fig. 17 Inverse concentration response C0h data from study 007
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In terms of safety, ataluren was generally well-tolerated by patients with nmDMD at the proposed
recommended dose of 10, 10, 20 mg/kg, as well as at the higher dose of 20, 20, 40 mg/kg, when
taken daily for 48 weeks in the Phase 2b Study 007. The adverse event profile of ataluren was
comparable to that of placebo. Most adverse events were mild or moderate, transient, and did
not require medical intervention. None of the patients discontinued treatment because of adverse
events. Few serious adverse events were reported, none was considered related to ataluren, and
no deaths occurred. Of note, an observational registry study was proposed by the Applicant to
collect additional long-term safety data.
Ground 2: The Applicant has not convincingly shown that comprehensive data can be obtained
from the confirmatory placebo-controlled trial if the product is authorised and available on the
market.
With regard to the completion of the Phase 3 confirmatory trial PTC124-GD-020-DMD (Study
020), the Applicant stated that as of 20 March 2014, 48 study sites were activated, with 163
patients screened and 125 patients randomized. The Applicant committed to completing the study
in a timely manner, allowing availability of results in 3Q 2015. Based on the advanced state of
study enrolment and a careful analysis of when market access to commercial drug would likely
occur in the concerned EU member states, the Applicant was of the view that only a very small
number of patients would be at risk of withdrawing, and maintained that the granting of the
conditional marketing authorisation should not jeopardize the completion or integrity of this
critical study. In this context, the Applicant referred to support from DMD patient advocacy
groups, existing patient-physician relationships and the option of continuing in a separate openlabel extension study as tools encouraging patients to complete the confirmatory trial.
Furthermore, the Applicant argued that the study 020 sample size was sufficiently large to allow
high integrity of conclusions even if some premature patient discontinuations should occur and
also flagged that their successful completion of the study 020 was critical in order to pursue
approval in other regions.
Overall CHMP conclusion on grounds for re-examination
The CHMP assessed all the detailed grounds for re-examination and argumentations presented by
the applicant in writing and in the oral explanation and considered the views expressed by the
Scientific Advisory Group in the initial phase of the procedure.
Ground 1
Following review of the non-clinical evidence available, the CHMP considered that effective
promotion of translation across premature nonsense stop codons was documented in various cell
culture systems as well as in vivo. In particular, the effects of ataluren observed in the zebrafish
sapje mutant and in the different genetic mouse models in vivo were considered of relevance in
terms of the mechanism of action claimed. With respect to the conflicting nature of some of the
results that was pointed out in the initial phase, the CHMP acknowledged that it may be attributed
to methodological differences of the respective assays. Overall, the mechanism of action of
ataluren (nonsense mutation readthrough) was considered plausible. Furthermore, the CHMP
noted that the maximum activity of ataluren in the non-clinical setting was mostly observed at
concentrations overlapping with the efficacious plasma levels of ataluren in the clinical studies
004 and 007, i.e. < 20 g/ml.
The CHMP considered that the activity of ataluren in cultures of myotubes from mdx mice and
nmDMD patients or MEFs of nmHurler mice in vitro and in mutant zebrafish larvae in vivo followed
a bell-shaped dose-response curve. In addition, results in nmHurler mice showed an inverse doseresponse relationship with the lowest dose being most effective, which was also indicative of the
above hypothesis of a bell shape. While some of the previous uncertainties related to the lack of
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verification of the findings by additional non-clinical in vivo data were maintained, overall, the
CHMP concluded that the bell-shaped dose-response could be considered implied by investigations
of atalurens activity in vitro and supported by data from in vivo study in sapje mutant zebrafish,
which constitutes a valuable complement to disease models in mammals.
With respect to clinical evidence of the bell-shaped dose response hypothesis, specific attention
was paid by the CHMP to the re-analyses of the treatment response in correlation to human plasma
concentrations of ataluren. The cut off value of < 19.3 g/ml used for categorization of patients in
low/high plasma level subjects was considered justified, as it was based on the range of C2h seen
in the low dose group (10, 10, 20 mg/kg). The results of this analysis indicated that patients in
study 007 who had lower plasma ataluren concentrations (< 19.3 g/ml) experienced less decline
in 6MWT than patients who had higher plasma ataluren concentrations. Furthermore, in their oral
explanation the Applicant presented additional analysis based on C0h values of plasma
concentration of ataluren, i.e. a parameter which approximately reflects the trough concentration.
Importantly, when looking at the efficacy by concentration, similarly to the observation based on
the C2h data, patients with low concentrations of ataluren performed better than those with high
concentration (both in terms of 6MWD and a across TFTs). Of note, the magnitude of the effect size
observed in patients with lower plasma concentration on the high dose and the one observed in the
patients on the low dose was similar in both instances, i.e. in the analyses based on C0h and C2h
data. This evidence was considered to provide support to the bell-shaped dose-response hypothesis
from the clinical point of view.
Overall, the CHMP was of the view that the bell-shaped dose response hypothesis was plausible
and that despite some limitations of the findings, the available evidence could provide a rationale
for the observed differences in efficacy between the two doses tested, i.e. higher efficacy seen in
the 10, 10, 20 mg/kg dose and minimal efficacy in the 20, 20, 40 mg/kg dose.
In light of the revised position of the CHMP on the mechanism of action and the bell-shaped doseresponse hypothesis, which were both parts of the initial grounds for refusal, the CHMP looked into
the available clinical efficacy data.
The CHMP maintained their initial position that there were limitations of the dataset in terms of
robustness, namely the observation of the variability of the primary efficacy data and the fact that
many of the conclusions supporting efficacy were derived from the post hoc analyses. However,
taking into account that the mechanistic concerns and concerns pertaining to the dose-response
were alleviated during the re-examination, as discussed above, the CHMP was of the view that the
observed results could reflect a true effect. This was considered to adequately reduce the concern
expressed during the initial phase, i.e. that the observed effects could be only chance findings.
With respect to the magnitude and clinical relevance of the observed effects, the CHMP referred to
their previous position, i.e. that there were several lines of evidence supporting the clinical
relevance of a 30-meter difference in 6MWT, including a report showing that a 30-meter change in
6MWD over 48 weeks can be considered a clinically meaningful change based on the
patient/parent-reported quality of life measures in DMD patients. This was also supported by
results of natural history data in DMD, indicating that 30-meter decrease in baseline 6MWD
significantly increases the risk of loss of ambulation over the following 2 years.
As in the initial phase of the MAA review, the CHMP discussed the appropriate target population for
the use of ataluren. Considering that the beneficial effects were most prominent in a subpopulation of ambulatory patients in the decline phase of their walking ability (effect size of
approximately 50 metres on the 6MWD), the CHMP discussed whether this finding would imply the
need for restricting the indication to a population defined accordingly, i.e. patients in ambulatory
decline phase. In line with the previous position of the SAG, the CHMP agreed that scientifically
there should be no reason for the drug not to be given to milder patients if efficacy had been
established in more severe ones. Furthermore, the CHMP considered that while less prominent, a
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clinically meaningful effect was seen also in the overall population studied. Thus, the CHMP
concluded that ataluren can be authorised in the indication that the company claimed in the reexamination:
Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a
nonsense mutation in the dystrophin gene, in ambulatory patients aged 5 years and older.
Efficacy has not been demonstrated in non-ambulatory patients.
The presence of a nonsense mutation in the dystrophin gene should be determined by genetic
testing.
Of note, the indication initially applied for, covering also non-ambulatory patients was not pursued
by the Applicant in their Grounds for re-examination. This was considered appropriate by the
CHMP, since ataluren was evaluated only in ambulatory patients.
The CHMP considered that the ground for refusal No. 1 was resolved with a specific obligation to
conduct the confirmatory clinical trial 020. The results of this trial were expected to further reduce
the uncertainties about benefits and support the favourable benefit-risk balance.
Ground 2
The CHMP reviewed the Applicants discussion about the feasibility of the confirmatory trial,
including the progress on recruitment, expected timelines and actions proposed to minimise patient
withdrawals and to ensure successful completion of the trial. Based on the assumptions made by
the Applicant, the CHMP agreed that conducting the confirmatory study 020 and submitting the
final study results by 4Q 2015 could be feasible independently of the status of approval. In
particular, the CHMP took into consideration the additional tools presented by the Applicant to
ensure that patients complete the confirmatory trial. These included existing patient-physician
relationships, the option of continuing participation in a separate open-label extension study and
also support from DMD patient advocacy groups which will be leveraged by the Applicant to
conduct outreach programmes for patients, emphasising the importance of remaining in study 020
through its completion. Furthermore, the CHMP considered that a protocol amendment will be
implemented by the Applicant allowing for additional recruitment, replacing patients who withdraw
from the study for reasons linked to the availability of the product on the market.
The CHMP concluded that the strategy of the Applicant was re-assuring and considered that the
ground for refusal No. 2 was resolved.
Overall conclusion
The Applicant applied for a conditional marketing authorisation with the proposal that additional
data would be generated post-authorisation in the confirmatory phase 3 study (020). Therefore,
the CHMP also re-discussed the criteria that would need to be met for a conditional approval
according to Articles 2 and 4 of the Regulation (EC) no 507/2006, and made the following
conclusions upon re-examination of the initial CHMP Opinion:
methods of treatment exist and it was considered that the product would thus address an unmet
medical need.
Upon review of the Applicants grounds for re-examination, the CHMP considered that
despite the uncertainties discussed above and the fact that the dataset was not comprehensive,
sufficient efficacy was seen to conclude on a favourable benefit-risk balance. Of note, this
conclusion was to a great extent supported by the safety profile of ataluren, which does not pose
any major safety concerns.
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The criterion that the benefits to public health of the immediate availability outweigh the
risks inherent in the fact that additional data are still required was considered fulfilled since the
benefits to public health were substantiated by providing a treatment for a serious disease,
characterised by gradual deterioration of the condition and a fatal outcome.
With respect to generating additional data post authorisation, the CHMP considered that
the Applicant will complete a confirmatory randomized placebo-controlled Phase 3 study PTC124GD-020-DMD (Study 020) with the 10, 10, 20 mg/kg/day dose in patients with nmDMD. The
CHMP agreed that this clinical trial may provide data alleviating the current uncertainties and
acknowledged the timelines planned for its conduct and submission of its results (4Q 2015). With
respect to the study feasibility, the position of the CHMP changed at the time of the reexamination Opinion; specifically, the CHMP considered that performing the study was plausible
per se, independent of the marketing authorisation status, as discussed above.
A favourable benefit-risk balance was established based on the data available at the time of this
MAA and the CHMP concluded that the confirmatory evidence from study 020 was acceptable to
be generated post authorisation.
2.
The summary table of risk minimisation measures should be edited to reflect the routine
risk minimisation measures planned for each safety concern (e.g. SmPC);
3.
Amendments are needed in the proposed SmPC to ensure accurate communication on the
monitoring requirements.
Of note, as requested by the PRAC during the initial phase of the MAA procedure, the PASS study
Long-Term Observational Study of Ataluren Safety and Effectiveness in Usual Care was classified
by the Applicant as a category 1 study. With respect to the scope of this PASS study, following a
review of the Applicants responses, it was concluded that it had been satisfactorily expanded to
obtain additional information on the long-term effectiveness of ataluren.
The Applicant addressed the above issues and produced an RMP based on the following content:
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Safety concerns
Summary of safety concerns
Important identified
risks
Important potential
risks
Missing information
corticosteroids
Renal toxicity
Hepatic toxicity
Hibernoma
Malignancies in general
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Pharmacovigilance plans
Study/activity type,
title and category
Objectives
Safety concern
addressed
Post-approval registry
Continue to
document the
long-term safety
profile of
ataluren
*re-classified to
category 3 at the
request of the CHMP,
see p. 93
Obtain additional
information on
the long-term
effectiveness of
ataluren
Evaluate the
safety and
effectiveness of
ataluren in
subgroups not
traditionally
included in
clinical trials
Evaluate changes
in lipid profile
Determine the
incidence and
frequency of:
o Hypertension
with use of
concomitant
corticosteroids
o Renal toxicity
(without
concomitant
aminoglycosides
or other
nephrotoxic
drugs)
o Hepatic toxicity
Status
(planned
/started)
Planned
Date for
submission of
interim or final
reports
(planned or
actual)
4Q2015 (1-year
interim)
4Q2016 (2-year
interim)
4Q2017 (3-year
interim)
4Q2018 (4-year
interim)
4Q2019 (5-year
interim)
4Q2020 (6-year
interim)
4Q2021 (7-year
interim)
4Q2022 (final)
Potential use in
children from 6 months
to 5 years
Use in patients whose
ethnic origin is other
than Caucasian
Extended long-term
safety
Off-label use in
patients who do not
have DMD caused by a
nonsense mutation in
the dystrophin gene
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
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Study/activity type,
title and category
Objectives
Safety concern
addressed
Status
(planned
/started)
Date for
submission of
interim or final
reports
(planned or
actual)
Potential use in
children from 6 months
to 5 years
Planned
December 2014
Potential use in
children from 6 months
to 5 years
Planned
December 2014
Potential use in
children from 6 months
to 5 years
Planned
December 2014
Evaluate the
safety of
ataluren
in patients with
moderate to
severe renal or
hepatic
impairment
when used with
nephrotoxic
drugs (other
than
aminoglycosides)
Evaluate the
safety and
effectiveness of
ataluren in the
context of
certain
concomitant
drugs
Monitor the
utilization
pattern of
ataluren
7-day tolerability and
pharmacokinetic study
in neonatal dogs
Category 3
1-month juvenile dose
range-finding toxicology
and toxicokinetic study
planned in neonatal
dogs (age correlating
with dosing in newborn
paediatric patients to 2
years of age), Study 2
of
EMA/PDCO/476743/201
2 PDCO document.
Category 3
3-month juvenile
toxicology and
toxicokinetic study
planned in neonatal
dogs (age correlating
with dosing in newborn
paediatric patients to 2
years of age), Study 3
of
EMA/PDCO/476743/201
2 PDCO document
Category 3
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Study/activity type,
title and category
Objectives
Further investigation of
atalurens potential
effect in the
development of
hibernomas
Planned
Date for
submission of
interim or final
reports
(planned or
actual)
December 2014
Further investigation of
atalurens potential
effect in the
development of
hibernomas
Planned
4Q2015
Potential use in
children from 6 months
to 5 years
Planned
December 2016
To evaluate the
safety and PK of
ataluren in
subjects with
different degrees
of hepatic
impairment, in
order to provide
guidance for
ataluren dosing
in patients with
moderate to
severe hepatic
impairment.
Planned
3Q2017
To evaluate the
safety and PK of
ataluren in
subjects with
different degrees
of renal
impairment, in
order to provide
guidance for
ataluren dosing
in patients with
moderate to
severe renal
impairment.
Planned
4Q2017
3 adrenergic binding
assay with ataluren and
the M4 metabolite, if
such a study is
technically feasible
Safety concern
addressed
Status
(planned
/started)
Category 3
Plan to investigate
further postauthorisation the
potential effects of
ataluren and metabolite
M4 in brown adipose
tissue of rats.
Category 3
Open-label safety and
PK study in children age
6 months to 5 years,
Study 6 of
EMA/PDCO/476743/201
2 PDCO document
Category 3
Safety and PK study in
patients with moderate
to severe hepatic
impairment
Category 3
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Study/activity type,
title and category
Objectives
Safety concern
addressed
To evaluate the
safety and PK of
ataluren and/or
the appropriate
sensitive probe,
in order to
provide guidance
for dosing
ataluren with the
specific
concomitant
medication.
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
Planned
Date for
submission of
interim or final
reports
(planned or
actual)
2Q2015
To evaluate the
safety and PK of
ataluren and/or
the appropriate
sensitive probe
substrate, in
order to provide
guidance for
dosing ataluren
with the specific
concomitant
medication.
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
Planned
4Q2015
To evaluate the
safety and PK of
ataluren and/or
the appropriate
sensitive probe,
in order to
provide guidance
for dosing
ataluren with the
specific
concomitant
medication.
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
Planned
2Q2016
To evaluate the
safety and PK of
ataluren and/or
the appropriate
sensitive probe
substrate, in
order to provide
guidance for
dosing ataluren
with the specific
concomitant
medication.
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
Planned
4Q2016
Category 3
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Status
(planned
/started)
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Study/activity type,
title and category
Objectives
Safety concern
addressed
To evaluate the
safety and PK of
ataluren and/or
the appropriate
sensitive probe
substrate, in
order to provide
guidance for
dosing ataluren
with the specific
concomitant
medication.
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
Planned
Date for
submission of
interim or final
reports
(planned or
actual)
2Q2017
To evaluate the
safety and PK of
ataluren and/or
the appropriate
sensitive probe
substrate, in
order to provide
guidance for
dosing ataluren
with the specific
concomitant
medication.
Effect of coadministration of
ataluren with certain
drugs not yet
evaluated in formal
drug-drug interaction
studies
Planned
2Q2018
Category 3
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Status
(planned
/started)
Page 88/101
Safety concerns
Potentiation of
aminoglycoside
renal toxicity
Additional risk
minimisation
measures
None proposed
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Safety concerns
Changes in lipid
profile
Additional risk
minimisation
measures
None proposed
None proposed
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Safety concerns
Renal toxicity
Additional risk
minimisation
measures
None proposed
None proposed
None proposed
Hibernoma
None proposed
None proposed
Malignancies in
general
None proposed
None proposed
Use of ataluren in
nmDMD patients
who coadministered
ataluren with
nephrotoxic drugs
None proposed
SmPC section 4.4 Special warnings and
precautions for use
Aminoglycosides
Since the mechanism by which ataluren increases
nephrotoxicity of intravenous aminoglycosides is not
known, concomitant use of other nephrotoxic medicinal
products with ataluren is not recommended. If this is
unavoidable (e.g. vancomycin to treat MRSA) careful
monitoring of renal function is advised (see section 4.5).
SmPC section 4.5 (Interaction with other
medicinal products and other forms of interaction)
The effect of co-administration of ataluren with other
nephrotoxic medicinal products is unknown.
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Additional risk
minimisation
measures
Safety concerns
Use of ataluren in
nmDMD patients
with moderate to
severe hepatic
impairment
None proposed
SmPC section 4.2 (Posology and method of
administration)
Renal and hepatic impairment
Safety and efficacy of ataluren in patients with renal and
hepatic impairment have not been established (see
section 4.4).
SmPC section 4.4 Special warnings and
precautions for use)
Hepatic and renal impairment
Patients with renal and hepatic impairments should be
closely monitored.
SmPC section 5.2 Pharmacokinetic properties
Renal or hepatic impairment
No studies have been conducted with Translarna in
patients with renal or hepatic impairment. Patients with
renal or hepatic impairment should be monitored
closely.
Use of ataluren in
nmDMD patients
with moderate to
severe renal
impairment
None proposed
SmPC section 4.2 Posology and method of
administration
Renal and hepatic impairment
Safety and efficacy of ataluren in patients with renal and
hepatic impairment have not been established.
SmPC section 4.4 Special warnings and
precautions for use
Hepatic and renal impairment
Patients with renal and hepatic impairments should be
closely monitored.
SmPC section 5.2 Pharmacokinetic properties
Renal or hepatic impairment
No studies have been conducted with Translarna in
patients with renal or hepatic impairment. Patients with
renal or hepatic impairment should be monitored
closely.
Potential use in
children from 6
months to 5 years
old
None proposed
SmPC section 4.1 (Therapeutic indications)
Translarna is indicated for the treatment of Duchenne
muscular dystrophy resulting from a nonsense mutation
in the dystrophin gene, in ambulatory patients aged 5
years and older.
SmPC section 4.2 (Posology and method of
administration)
The safety and efficacy of Translarna in children and
infants less than 5 years old have not yet been
established.
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Additional risk
minimisation
measures
Safety concerns
Use of ataluren in
patients whose
ethnic origin is
other than
Caucasian
None proposed
None proposed
Off-label use of
ataluren in
patients who do
not have DMD
caused by a
nonsense mutation
in the dystrophin
gene
None proposed
Effect of coadministration of
ataluren with
certain drugs not
yet evaluated in
formal drug-drug
interaction studies
None proposed
SmPC section 4.4 Special warnings and
precautions for use
Potential interactions with other medicinal products
Caution should be exercised when ataluren is coadministered with medicinal products that are
substrates or inducers of UGT1A9, inhibitors of BCRP, or
substrates of OAT1, OAT3, or OATP1B3 (section 4.5).
SmPC section 4.5 (Interaction with other
medicinal products and other forms of interaction)
Effect of other medicinal products on ataluren
pharmacokinetics
Based on in vitro studies, ataluren is a substrate of
UGT1A9 and breast cancer resistant protein (BCRP).
Caution should be exercised when ataluren is coadministered with medicinal products that are inducers
of UGT1A9 (e.g. mycophenolate mofetil), or inhibitors of
BCRP (e.g. ciclosporin).
Effect of ataluren on pharmacokinetics of other
medicinal products
Based on in vitro studies, ataluren is an inhibitor of
UGT1A9, organic anion transporter 1 (OAT1), organic
anion transporter 3 (OAT3) and organic anion
transporting polypeptide 1B3 (OATP1B3). Caution
should be exercised when ataluren is co-administered
with drugs that are substrates of UGT1A9, OAT1, OAT3,
or OATP1B3 because of the risk of increase
concentration of these medicinal products (eg,
oseltamivir, aciclovir, ciprofloxacin, captopril,
furosemide, bumetanide, valsartan, pravastatin,
rosuvastatin, atorvastatin, pitavastatin).
Based on the in vitro studies, ataluren is not expected
to be an inhibitor of neither p-gp mediated transport nor
of cytochrome P450 mediated metabolism. Similarly,
ataluren is not expected in vivo to be an inducer of
cytochrome P450 isoenzymes.
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5. Benefit-Risk Balance
Benefits
Beneficial effects
Ataluren is a first-in-class drug designed to enable ribosomal readthrough of premature stop
codons, resulting in the formation of a full-length functional protein in patients with nonsense
mutation genetic disorders. In the proof of concept study in mdx mice ataluren was seen to
promote formation and adequate localization of dystrophin, resulting in increased muscle strength
and prevention of loss of strength following repeated contractions.
In the clinical setting, beneficial effects of the lower dose (10, 10, 20 mg/kg) were claimed in
both primary and secondary endpoints of physical functioning.
With respect to 6MWD, ataluren was observed to slow disease progression in nmDMD patients.
The post-hoc analysis in the cITT population indicated an estimated difference in the Change in
6MWD at Week 48 of 31.7 metres (nominal p=0.0281, adjusted p=0.0561) between the 10, 10,
20 mg/kg dose and placebo. Looking at the proportions of patients with at least 10% worsening in
6MWD at Week 48, 44% vs 26% of patients in the placebo and the 10, 10, 20 mg/kg ataluren
arm, respectively were progressors (nominal p=0.0326, adjusted p=0.0652) .
A greater effect over 48 weeks was seen in patients in the ambulatory decline phase, i.e.
patients between 7 and 16 years of age, with baseline 6MWD 150m and 80% of predicted
value. Based on a post-hoc subgroup analysis in this population, a difference in the change in
6MWD at Week 48 of 49.9 metres (p=0.0096) between the 10, 10, 20 mg/kg dose and placebo
was seen.
In terms of secondary endpoints of physical functioning, only limited effects of ataluren were
observed: ataluren patients had fewer falls/week than placebo-dosed patients; increase of
wheelchair use from baseline was less in ataluren than placebo; ataluren patients spent less time
in no activity (based on Step activity monitoring) and a minor positive trend was observed in
myometry tests.
Uncertainty in the knowledge about the beneficial effects
The CHMP was of the view that the main uncertainties about the claimed beneficial effects
pertained to the dose-response curve (and hence the appropriate dose), the robustness of
efficacy data in general and the applicability of the data to the overall population of nmDMD
patients.
Uncertainties about the dose-response curve and dose
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The CHMP considered that the activity of ataluren in cultures of myotubes from mdx mice and
nmDMD patients or MEFs of nmHurler mice in vitro and in mutant zebrafish larvae in vivo followed
a bell-shaped dose-response curve. In addition, results in nmHurler mice showed an inverse doseresponse relationship with the lowest dose being most effective, which was also indicative of the
above hypothesis of a bell-shape dose-response. While some of the uncertainties related to the
lack of verification of the findings by additional non-clinical in vivo data were maintained, overall,
the CHMP concluded that the bell-shaped dose-response could be considered implied by
investigations of atalurens activity in vitro and supported by data from in vivo study in sapje
mutant zebrafish, which constitutes a valuable complement to disease models in mammals.
With respect to clinical evidence of the bell-shaped dose response hypothesis, specific attention
was paid by the CHMP to the re-analyses of the treatment response in correlation to human plasma
concentrations of ataluren. The cut off value of < 19.3 g/ml used for categorization of patients in
low/high plasma level subjects was considered justified, as it was based on the range of C2h seen
in the low dose group (10, 10, 20 mg/kg). The results of this analysis indicated that patients in
study 007 who had lower plasma ataluren concentrations (< 19.3 g/ml) experienced less decline
in 6MWT than patients who had higher plasma ataluren concentrations. Furthermore, in their oral
explanation the Applicant presented additional analysis based on C0h values of plasma
concentration of ataluren, i.e. a parameter which approximately reflects the trough concentration.
Importantly, when looking at the efficacy by concentration, similarly to the observation based on
the C2h data, patients with low concentrations of ataluren performed better than those with high
concentration (both in terms of 6MWD and a across TFTs). Of note, the magnitude of the effect size
observed in patients with lower plasma concentration on the high dose and the one observed in the
patients on the low dose was similar in both instances, i.e. in the analyses based on C0h and C2h
data. This evidence was considered to provide support to the bell-shaped dose-response hypothesis
from the clinical point of view.
Uncertainties about robustness of efficacy data
The CHMP was of the view that there were limitations of the dataset in terms of robustness,
namely the observation of the variability of the primary efficacy data and the fact that many of the
conclusions supporting efficacy were derived from the post hoc analyses. However, taking into
account that the mechanistic concerns and concerns pertaining to the dose-response were
alleviated during the re-examination, as discussed above, the CHMP concluded that the observed
results could reflect a true effect. This was considered adequate to reduce the concern expressed
during the initial phase, i.e. that the observed effects could be only chance findings.
The CHMP was of the view that the results on the secondary endpoints provided only limited
support for the primary endpoint outcomes and needed to be seen only as trends. Nevertheless, in
line with the previous input from the SAG, the CHMP acknowledged that most of the secondary
endpoints were of such nature that any effect would have to be driven by an increase in strength
and for this to occur, higher levels of dystrophin in muscular fibres would have to be achieved.
Pharmacodynamic confirmation of efficacy was not provided by the pivotal study, despite the fact
that biopsies were collected. While the technical problems with dystrophin quantification were
recognised by the CHMP, the quality of the biopsies supplied was of concern. The GCP inspection
identified that several steps were underestimated, namely instructions for performing the muscle
biopsies and the storage/ shipping logistics. Since the mechanism of action of ataluren is claimed
to be by promoting production of a full-length dystrophin, more prominent evidence of dystrophin
in muscle of patients treated for 48 weeks would be expected. Considering the limitations of data
on clinical efficacy, the CHMP pointed out that the dossier would have benefited from supportive
data on pharmacodynamics.
With respect to the actual mechanism of restoring dystrophin production, the CHMP considered
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that promotion of the translation process at the ribosomal level was plausible, despite the fact
that positive results were not seen in all assays reported.
Validity of data for the entire nmDMD patient population
Of note, the indication initially applied for, covering also non-ambulatory patients was not pursued
by the Applicant in their Grounds for re-examination. This was considered appropriate by the
CHMP, since ataluren was evaluated only in ambulatory patients.
Risks
Unfavourable effects
Ataluren was generally well tolerated by patients with nmDMD, with the most common adverse
events being headache and gastrointestinal disorders such as nausea, vomiting, (upper)
abdominal pain, flatulence, diarrhoea, stomach discomfort, constipation and regurgitation.
The laboratory data indicated that exposure to ataluren could cause elevation of serum
cholesterol and triglycerides. Mean cholesterol and triglycerides levels were in the upper range of
normal at baseline and increased to borderline-high or high levels in the ataluren arms, primarily
in patients who were receiving corticosteroids. The values tended to stabilize early and did not
increase further with continued treatment. Changes in the lipid profile were considered as an
important identified risk in the proposed Risk Management Plan.
Of note, elevations of serum creatinine occurred in several patients with nonsense mutation cystic
fibrosis treated concomitantly with intravenous aminoglycosides. In all cases, the elevations
resolved with discontinuation of the aminoglycosides indicating that co-administration of ataluren
and intravenous aminoglycosides may potentiate the nephrotoxic effect of the aminoglycosides.
Based on this evidence of decreased renal function, potentiation of aminoglycoside renal toxicity
was determined as an important identified risk.
There were no deaths during the placebo controlled study. Three fatal cases were seen in one
open-label study, but the fatal outcomes were not considered related to treatment with ataluren.
Uncertainty in the knowledge about the unfavourable effects
From the non-clinical database, the finding of malignant hibernomas in rat raised the concern as
to whether occurrence of similar effects could be expected in humans, particularly in the
paediatric population where the quantity of the brown adipose tissue is higher. In particular, the
CHMP considered that malignant hibernomas could be related to the effects of ataluren on fat
tissue metabolism and to effects on plasma lipid parameters, which were observed in rats, dogs
and humans. Thus, hibernomas were reflected in the proposed risk management plan of
ataluren as an important potential risk.
Considering the mechanism of action of ataluren, the CHMP pointed out a theoretical concern
about possible effects of ataluren on reading through normal stop codons (and thus producing
abnormally elongated proteins) and a concern that ataluren could enhance read through of nonsense mutations in other genes. Although such effects were not seen in the data available, the
CHMP was of the view that the potential off-target effects were an uncertainty about the risks of
ataluren.
Based on results of in vitro studies, ataluren was expected to have an interaction potential, which
the CHMP considered necessary to be explored further in vivo. This pertained to ataluren
interactions with a BCRP inhibitor, UGT1A9 substrate, OAT1, OAT3 and OATP1B3 substrates and
UGT1A9 selective inducer.
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studies
were
performed
and
potential
safety
concerns
are
implied
by
the
pharmacokinetics of ataluren. Since renal excretion accounts for ~ 50% of the drug elimination,
renal impairment is likely to result in accumulation of ataluren and/or ataluren glucuronide.
Similarly, since ataluren is extensively metabolized in liver, hepatic impairment is expected to
result in ataluren increased plasma concentrations. Taken together with the uncertainties around
the claimed bell-shaped dose-response curve, the CHMP considered that without clinical data,
understanding of both efficacy and safety profile of ataluren in subjects with renal or hepatic
impairment remains limited.
Benefit-risk balance
Importance of favourable and unfavourable effects
Several lines of evidence support the clinical relevance of a 30-meter difference in 6MWT,
including a report3 showing that a 30-meter change in 6MWD over 48 weeks can be considered a
clinically meaningful change based on the patient/parent-reported quality of life measures in DMD
patients. This is also supported by results of longitudinal LMWT natural history data in DMD,
indicating that each 30-meter decrease in baseline 6MWD predicts increasing risk of loss of
ambulation over the following 2 years.
Ability to climb and descend a short grouping of stairs, ability to run in short bursts, or to walk a
short distance unaided, e.g. to a bathroom, reflect the typical activities important in the lives of
DMD patients. Importantly, recent data indicated that timed function tests evaluating these
abilities are, similarly to 6MWT, predictive of the time for a patient to become non-ambulatory.
Natural history data from the Cooperative International Neuromuscular Group indicated that
3
Henricson E, Abresch R, Han JJ, Nicorici A, Goude Keller E, de Bie E, McDonald CM. The 6-Minute Walk Test and
Person-Reported Outcomes in Boys with Duchenne Muscular Dystrophy and Typically Developing Controls: Longitudinal
Comparisons and Clinically-Meaningful Changes Over One Year. PLOS Currents Muscular Dystrophy. 2013 Jul 8;
5:ecurrents.md.9e17658b007eb79fcd6f723089f79e06. doi:
10.1371/currents.md.9e17658b007eb79fcd6f723089f79e06
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changes in these parameters are predictive of the likelihood of loss of ambulation over 1 year.
Falls commonly lead to fractures in DMD patients and the injuries sustained may accelerate loss
of ambulation. Decreasing the rate of accidental falls and hence the risk of fractures, pain and
other trauma would be of benefit to the patients. With respect to decrease in wheel chair use,
benefits can be attributed not only in terms of ambulation itself, but also by positive impact on
the respiratory function and minimisation of scoliosis. Thus, if sufficiently documented these
effects would be considered of high importance.
The most commonly reported treatment-related adverse events vomiting, diarrhoea, abdominal
pain upper, flatulence, nausea, headache and decreased appetite were not considered to raise
major safety concerns in a seriously debilitating and life-threatening condition such as DMD.
The effect of ataluren on the lipid profile (cholesterol and triglyceride levels) was considered of
importance, especially in a situation where long-term administration of corticosteroids is
expected. Nevertheless, the values tended to stabilize early in the study and did not increase
further with continued treatment, which was considered re-assuring. Similarly, the risk of
hypertension during concomitant use of corticosteroids and ataluren was seen as of importance to
the target population, considering that such co-administration would occur in the majority of
patients in the clinical practice.
In the context of the age group targeted, the potential risk of hibernoma was considered relevant,
due to higher proportion of brown fat tissue in children.
Discussion on the benefit-risk balance
The CHMP considered that the data presented in the dossier had some deficiencies which impacted
on the benefit-risk assessment. In particular, the Applicant conducted only a single pivotal trial and
with the formal failure of its primary analysis, the efficacy discussion was based on post hoc
analyses. It was agreed that these analyses were performed in line with the most current
knowledge about the natural history of the disease (gained during the conduct of study 007), and
in this respect the definition of the subgroups in these analyses was clinically and scientifically
justified (e.g. patients in decline phase of their ambulation). The effects observed in the pivotal
study were considered generally encouraging, as also supported by the previous input from the
SAG, and in the context of a revised position on the mechanism of action and on the issue of doseresponse relationship, the CHMP was of the view that the observed results could reflect a true
effect and thus constitute evidence of efficacy.
As discussed above, the bell-shape dose response hypothesis was used by the Applicant to explain
why effects were only seen with the lower dose (10, 10, 20 mg/kg). Following re-examination of
the initial opinion the CHMP was of the view that, despite some limitations of the findings, the bellshaped dose response hypothesis was plausible and the available evidence could provide a
rationale for the observed differences in efficacy between the two doses tested, i.e. higher efficacy
seen in the 10, 10, 20 mg/kg dose and minimal efficacy in the 20, 20, 40 mg/kg dose.
The CHMP was of the view that the results on the secondary endpoints provided only limited
support for the primary endpoint outcomes and needed to be seen only as trends. Nevertheless, in
line with the previous input from the SAG, the CHMP acknowledged that most of the secondary
endpoints were of such nature that any effect would have to be driven by an increase in strength
and for this to occur, higher levels of dystrophin in muscular fibres would have to be achieved.
Although the safety data identified some safety concerns, in general these were considered
manageable through the implementation of adequate pharmacovigilance activities and risk
minimisation measures as described in the proposed Risk Management Plan. The lack of serious
toxic effects and the oral administration were also considered to represent clear advantages for a
population of mainly paediatric patients.
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Overall, the CHMP was of the view that the risks of the product could be considered acceptable and
that the data provided sufficient level of evidence that ataluren may be beneficial in delaying
disease progression in nmDMD. Therefore, the CHMP concluded that a favourable benefit-risk
balance could be established at this point.
As in the initial phase of the MAA review, the CHMP discussed the appropriate target population for
the use of ataluren. Considering that the beneficial effects were most prominent in a subpopulation of ambulatory patients in the decline phase of their walking ability (effect size of
approximately 50 metres on the 6MWD), the CHMP discussed whether this finding would imply the
need for restricting the indication to a population defined accordingly, i.e. patients in ambulatory
decline phase. In line with the previous position of the SAG, the CHMP agreed that scientifically
there should be no reason for the drug not to be given to milder patients if efficacy had been
established in more severe ones. Furthermore, the CHMP considered that while less prominent, a
clinically meaningful effect was seen also in the overall population studied. Thus, the CHMP
concluded that ataluren can be authorised in the indication:
Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a
nonsense mutation in the dystrophin gene, in ambulatory patients aged 5 years and older.
Efficacy has not been demonstrated in non-ambulatory patients.
The presence of a nonsense mutation in the dystrophin gene should be determined by genetic
testing.
The Applicant applied for a conditional marketing authorisation with the proposal that additional
data would be generated post-authorisation in the confirmatory phase 3 study PTC124-GD-020DMD (study 020). Therefore, the CHMP also re-discussed the criteria that would need to be met for
a conditional approval according to Articles 2 and 4 of the Regulation (EC) no 507/2006, and made
the following conclusions upon re-examination of the initial CHMP Opinion:
methods of treatment exist and it was considered that the product would thus address an unmet
medical need.
Upon review of the Applicants grounds for re-examination, the CHMP considered that
despite the uncertainties discussed above and the fact that the dataset was not comprehensive,
sufficient efficacy was seen to conclude on a favourable benefit-risk balance. Of note, this
conclusion was to a great extent supported by the safety profile of ataluren, which does not pose
any major safety concerns.
The criterion that the benefits to public health of the immediate availability outweigh the
risks inherent in the fact that additional data are still required was considered fulfilled since the
benefits to public health were substantiated by providing a treatment for a serious disease,
characterised by gradual deterioration of the condition and a fatal outcome.
With respect to generating additional data post authorisation, the CHMP considered that
the Applicant will complete a confirmatory randomized placebo-controlled Phase 3 study (study
020) with the 10, 10, 20 mg/kg/day dose in patients with nmDMD. The CHMP agreed that this
clinical trial may provide data alleviating the current uncertainties and acknowledged the timelines
planned for its conduct and submission of its results (4Q 2015). With respect to the study
feasibility, the position of the CHMP changed at the time of the re-examination Opinion;
specifically, the CHMP considered that performing the study was plausible per se, independent of
the marketing authorisation status.
A favourable benefit-risk balance was established based on the data available at the time of this
MAA and the CHMP concluded that the confirmatory evidence from study 020 was acceptable to
be generated post authorisation.
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Overall, the CHMP concluded that conditions for granting a conditional marketing authorisation
were met.
Recommendations following re-examination
Based on the arguments of the applicant and all the supporting data on quality, safety and efficacy,
the CHMP re-examined its initial opinion and in its final opinion concluded by majority decision that
the risk-benefit balance of Translarna indicated for
Translarna is indicated for the treatment of Duchenne muscular dystrophy resulting from a
nonsense mutation in the dystrophin gene, in ambulatory patients aged 5 years and older.
Efficacy has not been demonstrated in non-ambulatory patients.
The presence of a nonsense mutation in the dystrophin gene should be determined by genetic
testing.
is favourable and therefore recommends the granting of the conditional marketing authorisation
subject to the following conditions:
The marketing authorisation holder shall submit the first periodic safety update report for this
product within 6 months following authorisation. Subsequently, the marketing authorisation holder
shall submit periodic safety update reports for this product in accordance with the requirements set
out in the list of Union reference dates (EURD list) provided for under Article 107c(7) of Directive
2001/83/EC and published on the European medicines web-portal.
Conditions or restrictions with regard to the safe and effective use of the
medicinal product
The MAH shall perform the required pharmacovigilance activities and interventions detailed in the
agreed RMP presented in Module 1.8.2 of the Marketing Authorisation and any agreed subsequent
updates of the RMP.
An updated RMP should be submitted:
Whenever the risk management system is modified, especially as the result of new
information being received that may lead to a significant change to the benefit/risk profile
or as the result of an important (pharmacovigilance or risk minimisation) milestone being
reached.
If the dates for submission of a PSUR and the update of a RMP coincide, they can be submitted at
the same time.
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complete
Due date
a
multicentre,
randomised,
double-blind,
placebo-controlled
Submission
confirmatory study to examine efficacy and safety of ataluren 10, 10, 20 mg/kg
of
report:
the
final
PTC124-GD-020-DMD)
By 4Q 2015
Conditions or restrictions with regard to the safe and effective use of the
medicinal product to be implemented by the Member States
Not applicable.
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The undersigned members of the CHMP did not agree with the CHMPs negative opinion
recommending the refusal of the granting of a conditional approval of Translarna in the indication
treatment of Duchenne muscular dystrophy resulting from a nonsense mutation in the dystrophin
gene, in patients aged 5 years and older.
The reasons for the divergent opinion are as follows:
Translarna was developed to address the unmet medical need of the small fraction of patients with
Duchenne muscular dystrophy (DMD) caused by a nonsense mutation, estimated to be 2500
patients (13%) of the European DMD population (~19000 patients). There are no remaining issues
from the Quality point of view, and although some Non-clinical issues are still identified, they can
be followed-up post approval. Considering the Clinical data, although the results are not sufficiently
robust for a full Marketing Authorisation, the demonstrated effects are considered to be
encouraging. The robustness of the results was challenged because of the observed variability in
the primary efficacy data, the fact that many of the important conclusions supporting efficacy were
derived from post hoc analyses and the fact that there was little supportive evidence of effect from
the data on the secondary endpoints. It is recognized that at the time the study was designed the
knowledge of the natural history of the disease was different from what we currently know.
Therefore, the post hoc analyses reflecting the most current knowledge about the natural history of
the disease, and in this respect the definition of the sub-groups in these analyses is clinically and
scientifically justified. In agreement with the SAG experts, results derived from these analyses may
be considered clinically relevant, especially in the sub-group of patients with more advanced
disease. Additionally, the lack of effect on the secondary endpoints could be explained by the
expected mechanism of action of the drug i.e. partial restoration of dystrophin production. Most of
the secondary endpoints are of such nature that any effect will have to be driven by an increase in
strength, rather than by an improvement of function. The latest available data suggest that
minimal increase in dystrophin production could lead to functional improvement, but not to
improvement of strength. For the latter to occur, levels of dystrophin close to the ones in normal
muscular fibres may need to be achieved. This could be a valid explanation of the lack of
concordance between the results on the primary and secondary efficacy endpoints. The group also
noted that, despite the fact that efficacy was most prominently shown in the sub-group of patients
with more advanced disease, there were trends of efficacy in all the sub-groups by severity,
although of a different magnitude. This finding may be expected since the decline in function of
DMD patients is not linear, but rather the speed of functional decline increases with the duration of
the disease. In that respect, it would be very difficult to show a significant functional improvement
in mildly affected patients in the frame of a controlled clinical trial with duration of 1 or 2 years. On
the contrary, in more severely affected patients even a small effect on function could be detectable
and clinically meaningful. It should be acknowledged that, in these patients, even small effects
providing longer independent use of arms and hands, or preserving the ability to feed and drink
from a cup on their own, would represent a significant and important achievement.
Taking all of the above into consideration and in the absence of major safety concerns, the
minority view was that a positive benefit/risk relationship of ataluren has been reasonably
established in Duchenne patients with nonsense mutations and, consequently, treatment with
ataluren should not be withheld from these patients. A conditional approval with the ongoing phase
III trial as condition was considered acceptable. In addition, the long-term benefit of ataluren in
this population could be documented by following patients up in specific registries.
Overall, and under the scope of a conditional approval, the B/R balance is considered to be positive
in the following indication: Duchenne muscular dystrophy (nmDMD) caused by nonsense mutation
in the dystrophin gene, in ambulatory patients aged 5 and older.
London, 23 January 2014
Jan Mueller-Berghaus
Bruno Sepodes
Jean-Louis Robert
Natalja Karpova
Jan Mazag
Daniela Melchiorri
Jens Heisterberg
Pierre Demolis
Harald Enzmann
Jacqueline Genoux-Hames
The undersigned member(s) of the CHMP did not agree with the CHMPs positive opinion
recommending the granting of the marketing authorisation of Translarna indicated in the treatment
of Duchenne muscular dystrophy resulting from a nonsense mutation in the dystrophin gene, in
ambulatory patients aged 5 years and older.
The single study fails to demonstrate evidence of therapeutic efficacy of Translarna either
on the primary endpoint (6MWD) or on secondary efficacy measures. The study failed on
its primary endpoint analysis and efficacy claims are based on post hoc revisions to the
analysis and on subgroup analyses. The argument that efficacy could be shown more easily
in the decline phase subgroup seems plausible, based on data on the natural history of the
disease, and it is agreed that confirmation of efficacy in these patients could be in principle
extrapolated to support a general indication in DMD. However there are concerns that the
presented analyses in this subgroup might be data driven i.e. the inclusion or exclusion
from the subgroup of a few patients with a large change in 6MWD (depending on how the
population is defined) could substantially affect the analysis. In this context it is noted that
the corresponding analysis in the pre-specified <350 metre (baseline 6MWD) subgroup was
much less impressive than in the post hoc defined decline phase subgroup. The mechanism
of action of Translarna and an effect on a relevant pharmacodynamic measure have not
been conclusively established, which adds further uncertainty. There is some evidence for
the bell shape dose-response relationship but still some uncertainty. The numerous
assumptions that need to be made to accept the claim that efficacy is shown for the low
dose (but not the high dose) in the decline phase subgroup is considered problematic.
Confirmatory data from on-going phase 3 trial are considered necessary and a positive
benefit-risk balance has not been established at the present time due to a lack of evidence
of efficacy.
Alar Irs
Sol Ruiz
Robert Hemmings
Ondrej Slanar
Daniel Brasseur
David Lyons
Greg Markey
Dinah Duarte
Pieter de Graeff
Reynir Arngrimsson
Romaldas Maciulaitis